Silver Classic CSR 250, Silver, Child-Only, ST, INN, Circle, Wellness Rewards DP FP – EPO

Description

This plan has 73% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	EPO
Deductible	$1,925 per person $1,925 per person
Out-of-pocket max	$7,550 per person $15,100 per family
Metal tier	Silver

Visit Copay

Primary care visit	first 1 visit(s) $30 then $30 copay after deductible
Specialist visit	first 1 visit(s) $65 then $65 copay after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	first 1 visit(s) $70 then $70 copay after deductible
Emergency room	$275 copay after deductible
Ambulance	$150 copay after deductible
Hospital stay (facility)	$1,500 copay after deductible
Hospital stay (physician)	$150 copay after deductible
Outpatient procedure (facility)	$150 copay after deductible
Outpatient procedure (physician)	$150 copay after deductible
Physical rehabilitation	$30 copay after deductible

Maternitowny and Pregnancy

Labor, delivery, hospital stay

$1,500 copay after deductible

Pharmacy, Drugs, and Medication

Generic	$15 copay
Brand	$40 copay
Non-preferred Brand	$75 copay

Lab Tests and Diagnostic Procedures

X-rays	$75 copay after deductible
Imaging (CT/PET/MRI)	$175 copay after deductible
Blood work	$50 copay after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	first 1 visit(s) $30 then $30 copay after deductible
Psychiatric hospital stay	$1,500 copay after deductible

Health Plan Provider Information

Health Plan Benefits

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