Silver Valley Advantage EPO 450/0/3 CSR94 + Silver + EPO – EPO
94% cost sharing reduction [Popular Plan]
Network type: EPO
Coverage tier: Silver
Primary care visit: $3 copay
Specialist visit: $5 copay
Urgent care visit: $20 copay
Description
This plan has 94% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | EPO |
| Deductible | $450 per person $450 per person |
| Out-of-pocket max | $1,000 per person $2,000 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $3 copay |
| Specialist visit | $5 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $20 copay |
| Emergency room | $50 copay after deductible |
| Ambulance | No charge after deductible |
| Hospital stay (facility) | No charge after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | No charge after deductible |
| Outpatient procedure (physician) | No charge after deductible |
| Physical rehabilitation | $5 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | No charge after deductible |
Pharmacy, Drugs, and Medication
| Generic | $2 per script copay |
| Brand | $10 per script after deductible copay |
| Non-preferred Brand | $25 per script after deductible copay |
| Specialty | 10% after deductible, up to $200 per script copay, 10% after deductible, up to $200 per script |
Lab Tests and Diagnostic Procedures
| X-rays | No charge after deductible |
| Imaging (CT/PET/MRI) | 10% after deductible |
| Blood work | No charge after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $3 copay |
| Psychiatric hospital stay | No charge after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/GAKHxwdjVvQtNnTpv67adhdZ.pdf |
| Drug and medication plan formulary | https://www.healthcare.gov/sbc-glossary/#prescription-drug-coverage |
