Silver PPO 1750/5/5 CSR87 + Silver + PPO – PPO
87% cost sharing reduction [Popular Plan]
Network type: PPO
Coverage tier: Silver
Primary care visit: $5 copay
Specialist visit: $10 copay
Urgent care visit: $35 copay
Description
This plan has 87% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | PPO |
| Deductible | $1,750 per person $1,750 per person |
| Out-of-pocket max | $3,150 per person $6,300 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $5 copay |
| Specialist visit | $10 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $35 copay |
| Emergency room | $75 copay after deductible |
| Ambulance | 5% after deductible |
| Hospital stay (facility) | 5% after deductible |
| Hospital stay (physician) | 5% after deductible |
| Outpatient procedure (facility) | 5% after deductible |
| Outpatient procedure (physician) | 5% after deductible |
| Physical rehabilitation | $10 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 5% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $3 per script copay |
| Brand | $15 per script after deductible copay |
| Non-preferred Brand | $40 per script after deductible copay |
| Specialty | 30% after deductible, up to $400 per script copay, 30% after deductible, up to $400 per script |
Lab Tests and Diagnostic Procedures
| X-rays | 5% after deductible |
| Imaging (CT/PET/MRI) | 15% after deductible |
| Blood work | $15 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $5 copay |
| Psychiatric hospital stay | 5% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/s3AaLjmpNw3RrDhzW5Lvbzpt.pdf |
| Drug and medication plan formulary | https://www.healthcare.gov/sbc-glossary/#prescription-drug-coverage |
