Freedom Silver 87 – POS

Description

This plan has 87% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	POS
Deductible	$500 per person $500 per person
Out-of-pocket max	$2,700 per person $5,400 per family
Metal tier	Silver

Visit Copay

Primary care visit	$15 copay
Specialist visit	$35 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$35 copay
Emergency room	$350 copay after deductible
Ambulance	20% coinsurance after deductible
Hospital stay (facility)	$750 copay per Day after deductible
Hospital stay (physician)	No charge after deductible
Outpatient procedure (facility)	$500 copay after deductible
Outpatient procedure (physician)	No charge after deductible
Physical rehabilitation	$15 copay after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	$2250 copay after deductible

Pharmacy, Drugs, and Medication

Generic	$10 copay
Brand	$60 copay after deductible
Non-preferred Brand	$75 copay after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	$200 copay after deductible
Imaging (CT/PET/MRI)	$200 copay after deductible
Blood work	No charge after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$15 copay
Psychiatric hospital stay	$750 copay per Day after deductible

Health Plan Provider Information

Health Plan Benefits	https://PrimewellHealth.com/documents/Marketplace/2024INDFreedomSilver87SummaryOfBenefitsAndCoverage.pdf
Drug and medication plan formulary	https://PrimewellHealth.com/documents/Marketplace/2024CommercialAndExchangeMemberListOfCoveredDrugs(Formulary).pdf
Search doctor list	https://PrimewellHealth.com/provider/providersearch