Select Silver 150 Ded/1000 MOOP 94% (4900/7900) – HMO
94% cost sharing reduction [Popular Plan]
Network type: HMO
Coverage tier: Silver
Primary care visit: $15 copay
Specialist visit: $30 copay
Urgent care visit: $15 copay
Description
This plan has 94% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | HMO |
| Deductible | $150 per person $150 per person |
| Out-of-pocket max | $1,000 per person $2,000 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $15 copay |
| Specialist visit | $30 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $15 copay |
| Emergency room | 5% coinsurance after deductible |
| Ambulance | 5% coinsurance after deductible |
| Hospital stay (facility) | 5% coinsurance after deductible |
| Hospital stay (physician) | 5% coinsurance after deductible |
| Outpatient procedure (facility) | 5% coinsurance after deductible |
| Outpatient procedure (physician) | 5% coinsurance after deductible |
| Physical rehabilitation | 5% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 5% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | $30 copay |
| Non-preferred Brand | $150 copay |
| Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 5% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 5% coinsurance after deductible |
| Blood work | 5% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $15 copay |
| Psychiatric hospital stay | 5% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://planfinder.ghcscw.com/sbc/2412358.pdf |
| Drug and medication plan formulary | https://ghcscw.com/members/understanding-your-pharmacy-benefits/ |
| Search doctor list | https://providersearch.ghcscw.com/public/#/ |
