Essential Gold 1500 – POS

Description

Health Care Plan Details

Network type	POS
Deductible	$1,500 per person $1,500 per person
Out-of-pocket max	$7,800 per person $15,600 per family
Metal tier	Gold

Visit Copay

Primary care visit	$20 copay
Specialist visit	20% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	20% coinsurance after deductible
Emergency room	20% coinsurance after deductible
Ambulance	20% coinsurance after deductible
Hospital stay (facility)	20% coinsurance after deductible
Hospital stay (physician)	20% coinsurance after deductible
Outpatient procedure (facility)	20% coinsurance after deductible
Outpatient procedure (physician)	20% coinsurance after deductible
Physical rehabilitation	20% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	20% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$15 copay
Brand	20% coinsurance after deductible
Non-preferred Brand	20% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	20% coinsurance after deductible
Imaging (CT/PET/MRI)	20% coinsurance after deductible
Blood work	20% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$20 copay
Psychiatric hospital stay	20% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://PrimewellHealth.com/documents/Marketplace/2024INDEssentialGold1500SummaryOfBenefitsAndCoverage.pdf
Drug and medication plan formulary	https://PrimewellHealth.com/documents/Marketplace/2024CommercialAndExchangeMemberListOfCoveredDrugs(Formulary).pdf
Search doctor list	https://PrimewellHealth.com/provider/providersearch