Innovation Health – Aetna Silver 3: HMO – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $35 copay
Specialist visit: $70 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $6,400 per person $6,400 per person |
| Out-of-pocket max | $9,200 per person $18,400 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $35 copay |
| Specialist visit | $70 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $750 copay |
| Ambulance | $750 copay |
| Hospital stay (facility) | 40% after deductible |
| Hospital stay (physician) | 40% after deductible |
| Outpatient procedure (facility) | 40% after deductible |
| Outpatient procedure (physician) | 40% after deductible |
| Physical rehabilitation | $70 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 40% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $25 per script copay |
| Brand | $55 per script copay |
| Non-preferred Brand | 40% after deductible |
| Specialty | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $25 copay after deductible |
| Imaging (CT/PET/MRI) | 40% after deductible |
| Blood work | $55 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $35 copay |
| Psychiatric hospital stay | 40% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/6A2f7rqkfau814Fz7b2iuqFR.pdf |
| Drug and medication plan formulary | https://client.formularynavigator.com/Search.aspx?siteCode=6179884039 |
