Gold Select w/ GYM – Limited Service Area – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $20 copay
Specialist visit: $50 copay
Urgent care visit: $20 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $2,800 per person $2,800 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $20 copay |
| Specialist visit | $50 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $20 copay |
| Emergency room | 20% after deductible |
| Ambulance | 20% after deductible |
| Hospital stay (facility) | first 5 day(s) $500 per day then $0 copay |
| Hospital stay (physician) | 20% after deductible |
| Outpatient procedure (facility) | 20% after deductible |
| Outpatient procedure (physician) | 20% after deductible |
| Physical rehabilitation | $20 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | first 5 day(s) $500 then $0 copay |
Pharmacy, Drugs, and Medication
| Generic | No charge |
| Brand | $50 copay |
| Non-preferred Brand | $125 copay |
| Specialty | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $45 copay |
| Imaging (CT/PET/MRI) | $210 copay |
| Blood work | $15 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | No charge |
| Psychiatric hospital stay | No charge |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/miVEGny2S9aD5TM3SkFAeiv4.pdf |
| Drug and medication plan formulary | https://client.formularynavigator.com/Search.aspx?siteCode=0324498195 |
