Silver Elite Saver Plus – PPO

Network type: PPO
Coverage tier: Silver
Primary care visit: $60 copay
Specialist visit: $100 copay
Urgent care visit: $50 copay

Description

Health Care Plan Details

Network type PPO
Deductible $0 per person $0 per person
Out-of-pocket max $9,100 per person $18,200 per family
Metal tier Silver

Visit Copay

Primary care visit $60 copay
Specialist visit $100 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $50 copay
Emergency room 50% coinsurance
Ambulance 50% coinsurance
Hospital stay (facility) 50% coinsurance
Hospital stay (physician) 50% coinsurance
Outpatient procedure (facility) 50% coinsurance
Outpatient procedure (physician) 50% coinsurance
Physical rehabilitation $100 copay

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay 50% coinsurance

Pharmacy, Drugs, and Medication

Generic $3 copay
Brand $125 copay
Non-preferred Brand 50% coinsurance after deductible
Specialty 50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays $100 copay
Imaging (CT/PET/MRI) 50% coinsurance
Blood work $10 copay

Mental and Psychiatric Health Care

Mental Health outpatient services $60 copay
Psychiatric hospital stay 50% coinsurance

Health Plan Provider Information

Health Plan Benefits https://d3ul0st9g52g6o.cloudfront.net/2024/OK/sbc/2024_91908OK001003001.pdf
Drug and medication plan formulary https://www.hioscar.com/search-documents/drug-formularies/
Search doctor list https://www.hioscar.com/search/?networkId=045&year=2024