Connect 5000 Silver – EPO

Description

This plan has 94% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	EPO
Deductible	$250 per person $250 per person
Out-of-pocket max	$1,000 per person $2,000 per family
Metal tier	Silver

Visit Copay

Primary care visit	$5 copay
Specialist visit	$15 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$15 copay
Emergency room	$250 copay after deductible, 10% coinsurance after deductible
Ambulance	10% coinsurance after deductible
Hospital stay (facility)	10% coinsurance after deductible
Hospital stay (physician)	10% coinsurance after deductible
Outpatient procedure (facility)	10% coinsurance after deductible
Outpatient procedure (physician)	10% coinsurance after deductible
Physical rehabilitation	10% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	10% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$5 copay
Brand	$30 copay
Non-preferred Brand	25% coinsurance after deductible
Specialty	25% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	10% coinsurance
Imaging (CT/PET/MRI)	10% coinsurance after deductible
Blood work	10% coinsurance

Mental and Psychiatric Health Care

Mental Health outpatient services	$5 copay
Psychiatric hospital stay	10% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://providencehealthplan.com/-/media/providence/website/pdfs/indi-fam/2024/SBC/OR/2024_Connect_5000_Silver_06.pdf
Drug and medication plan formulary	http://www.ProvidenceHealthPlan.com/2024FormularyN
Search doctor list	https://providencehealthplan.com/connectphppd