SELECT GOLD I420-01 VALUE TIER RX – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $15 copay
Specialist visit: $90 copay
Urgent care visit: $90 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $1,000 per person $1,000 per person |
| Out-of-pocket max | $8,500 per person $17,000 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $15 copay |
| Specialist visit | $90 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $90 copay |
| Emergency room | $500 copay |
| 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 | 40% after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 40% after deductible |
Pharmacy, Drugs, and Medication
| Generic | No charge |
| Brand | No charge |
| Non-preferred Brand | 50% coinsurance |
| Specialty | 60% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $90 per day copay |
| Imaging (CT/PET/MRI) | 40% after deductible |
| Blood work | $30 per day copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $15 copay |
| Psychiatric hospital stay | 40% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/15csHqJuoFG5c84VuvMh7vbb.pdf |
| Drug and medication plan formulary | https://quartzbenefits.com/members/pharmacy-program/covered-drugs/standard-formularies/ |
