Silver Classic CSR 200, Silver, ST, INN, Circle Wellness Rewards DP FP Dep 29 – EPO
87% cost sharing reduction [Popular Plan]
Network type: EPO
Coverage tier: Silver
Primary care visit: first 1 visit(s) $15 then $15 copay after deductible
Specialist visit: first 1 visit(s) $35 then $35 copay after deductible
Urgent care visit: first 1 visit(s) $50 then $50 copay after deductible
Description
This plan has 87% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | EPO |
| Deductible | $275 per person $275 per person |
| Out-of-pocket max | $3,150 per person $6,300 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | first 1 visit(s) $15 then $15 copay after deductible |
| Specialist visit | first 1 visit(s) $35 then $35 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | first 1 visit(s) $50 then $50 copay after deductible |
| Emergency room | $75 copay after deductible |
| Ambulance | $75 copay after deductible |
| Hospital stay (facility) | $250 copay after deductible |
| Hospital stay (physician) | $75 copay after deductible |
| Outpatient procedure (facility) | $75 copay after deductible |
| Outpatient procedure (physician) | $75 copay after deductible |
| Physical rehabilitation | $25 copay after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $250 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $9 copay |
| Brand | $20 copay |
| Non-preferred Brand | $40 copay |
Lab Tests and Diagnostic Procedures
| X-rays | $35 copay after deductible |
| Imaging (CT/PET/MRI) | $35 copay after deductible |
| Blood work | $35 copay after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | first 1 visit(s) $15 then $15 copay after deductible |
| Psychiatric hospital stay | $250 copay after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/jNmkaEZrfdT8JrRmCZSNfbJ3.pdf |
