Gold+ w/ TytoHome and GYM – Limited Service Area – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: first 3 visit(s) $50 then 20% after deductible copay, first 3 visit(s) $50 then 20% after deductible
Specialist visit: $90 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 | Gold |
Visit Copay
| Primary care visit | first 3 visit(s) $50 then 20% after deductible copay, first 3 visit(s) $50 then 20% after deductible |
| Specialist visit | $90 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $750 copay |
| Ambulance | $250 copay after deductible |
| Hospital stay (facility) | 20% after deductible |
| Hospital stay (physician) | 20% after deductible |
| Outpatient procedure (facility) | 20% after deductible |
| Outpatient procedure (physician) | 20% after deductible |
| Physical rehabilitation | $50 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 20% after deductible |
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 | $100 copay |
| Imaging (CT/PET/MRI) | 20% after deductible |
| Blood work | $10 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/KrnQT3we6JdBgtuTdJTcDZ6W.pdf |
| Drug and medication plan formulary | https://client.formularynavigator.com/Search.aspx?siteCode=0324498195 |
