Health Options $4000 HMO National Off MP – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: first 1 visit(s) $0 then $50 copay
Specialist visit: $85 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | See brochure See brochure |
| Out-of-pocket max | N/A per person N/A per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | first 1 visit(s) $0 then $50 copay |
| Specialist visit | $85 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | 40% after deductible |
| Ambulance | 40% after deductible |
| Hospital stay (facility) | 40% after deductible |
| Hospital stay (physician) | 40% after deductible |
| Outpatient procedure (facility) | 40% after deductible |
| Outpatient procedure (physician) | 40% after deductible |
| Physical rehabilitation | $50 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 40% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $5 copay |
| Brand | $70 copay |
| Non-preferred Brand | 30% after deductible, up to $400 per script copay, 30% after deductible, up to $400 per script |
| Specialty | 30% after deductible, up to $500 per script copay, 30% after deductible, up to $500 per script |
Lab Tests and Diagnostic Procedures
| X-rays | 40% after deductible |
| Imaging (CT/PET/MRI) | 40% after deductible |
| Blood work | 40% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | first 1 visit(s) $0 then $50 copay |
| Psychiatric hospital stay | 40% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/THgzK9jP6dJJq7PuJ6744gPk.pdf |
| Drug and medication plan formulary | https://www.healthoptions.org/members/medications#drug-formulary |
