Silver 4000 Deductible – EPO

Description

This plan has 73% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	EPO
Deductible	Success Your progress has been saved. We have sent an email to with a link to continue your application ×
Out-of-pocket max	$7,550 per person $15,100 per family
Metal tier	Silver

Visit Copay

Primary care visit	$20 copay
Specialist visit	$70 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$70 copay
Emergency room	30% coinsurance after deductible
Ambulance	30% coinsurance after deductible
Hospital stay (facility)	30% coinsurance after deductible
Hospital stay (physician)	30% coinsurance after deductible
Outpatient procedure (facility)	30% coinsurance after deductible
Outpatient procedure (physician)	30% coinsurance after deductible
Physical rehabilitation	30% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	30% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$10 copay
Brand	30% coinsurance after deductible
Non-preferred Brand	50% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	30% coinsurance after deductible
Imaging (CT/PET/MRI)	30% coinsurance after deductible
Blood work	30% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$20 copay
Psychiatric hospital stay	30% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://regence.com/go/2024/SBC/UT/Silver4000Deductible73IFNEx
Drug and medication plan formulary	https://regence.com/go/2024/UT/4tier
Search doctor list	https://regence.com/go/UT/IFN