MercyCare HMO Gold Standard – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$1,500 per person $1,500 per person
Out-of-pocket max	$8,700 per person $17,400 per family
Metal tier	Gold

Visit Copay

Primary care visit	$30 copay
Specialist visit	$60 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$45 copay
Emergency room	25% coinsurance after deductible
Ambulance	25% coinsurance after deductible
Hospital stay (facility)	25% coinsurance after deductible
Hospital stay (physician)	25% coinsurance after deductible
Outpatient procedure (facility)	25% coinsurance after deductible
Outpatient procedure (physician)	25% coinsurance after deductible
Physical rehabilitation	$30 copay

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	25% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$15 copay
Brand	$30 copay
Non-preferred Brand	$60 copay
Specialty	$250 copay

Lab Tests and Diagnostic Procedures

X-rays	25% coinsurance after deductible
Imaging (CT/PET/MRI)	25% coinsurance after deductible
Blood work	25% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$30 copay
Psychiatric hospital stay	25% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://res.cloudinary.com/dpmykpsih/image/upload/mercyhealth-site-398/media/3cecfdb1aab543ecad9e16becba0b3aa/2024-jan-sbc-gold-standard-co-75-1500-ded-wi58326wi0090021_091223.pdf
Drug and medication plan formulary	https://res.cloudinary.com/dpmykpsih/image/upload/mercyhealth-site-398/media/63f009c4df4441b894923f17ebbb4e1b/wi-qhp-formulary-011124.pdf
Search doctor list	https://www.mercycarehealthplans.com/find-a-providerfacility/