Prevea360 Silver Copay Plus 1000X (Free Virtual Care) – HMO

Description

This plan has 87% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	HMO
Deductible	$1,000 per person $1,000 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	$80 copay
Preventive care visit	No data available

Urgent, Emergency Care, and Hospital Care

Urgent care	$5 copay
Emergency room	$500 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	$5 copay

Maternitowny and Pregnancy

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

Pharmacy, Drugs, and Medication

Generic	$5 copay
Brand	$60 copay
Non-preferred Brand	50% coinsurance
Specialty	50% coinsurance

Lab Tests and Diagnostic Procedures

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

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://sbc.prevea360.com/api/GetPdfFile/true/Prevea360-Silver-Copay-Plus-1000X05_0124.PDF
Drug and medication plan formulary	https://www.prevea360.com/WIDrugList-2024
Search doctor list	https://www.prevea360.com/SearchPrevea360Network-2024