SummaCare Silver 1050-87 with 3 Free PCP Visits – HMO
87% cost sharing reduction [Popular Plan]
Network type: HMO
Coverage tier: Silver
Primary care visit: $5 copay
Specialist visit: $20 copay
Urgent care visit: $75 copay
Description
This plan has 87% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | HMO |
| Deductible | $1,050 per person $1,050 per person |
| Out-of-pocket max | $3,000 per person $6,000 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $5 copay |
| Specialist visit | $20 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay |
| Emergency room | $500 copay after deductible |
| Ambulance | 20% coinsurance after deductible |
| Hospital stay (facility) | 20% coinsurance after deductible |
| Hospital stay (physician) | 20% coinsurance after deductible |
| Outpatient procedure (facility) | $300 copay after deductible |
| Outpatient procedure (physician) | 20% coinsurance after deductible |
| Physical rehabilitation | $20 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 20% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $5 copay |
| Brand | $30 copay after deductible |
| Non-preferred Brand | 50% coinsurance after deductible |
| Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 20% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 20% coinsurance after deductible |
| Blood work | 20% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $5 copay |
| Psychiatric hospital stay | 20% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.summacare.com/-/media/Project/SummaCare/Website/Document-Library/SBCs/IFP/2024/2024-SBC-SummaCare-Silver-1050-87-EHB-Only.pdf |
| Drug and medication plan formulary | https://client.formularynavigator.com/Search.aspx?siteCode=3823697592 |
| Search doctor list | https://www.summacare.com/scconnect |
