2024 POS 4200 Elite Silver – POS
Network type: POS
Coverage tier: Silver
Primary care visit: $35 copay
Specialist visit: $55 copay
Urgent care visit: $55 copay
Description
Health Care Plan Details
| Network type | POS |
| Deductible | $4,200 per person $4,200 per person |
| Out-of-pocket max | $8,750 per person $17,500 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $35 copay |
| Specialist visit | $55 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $55 copay |
| Emergency room | 40% coinsurance after deductible |
| Ambulance | 40% coinsurance after deductible |
| Hospital stay (facility) | 40% coinsurance after deductible |
| Hospital stay (physician) | 40% coinsurance after deductible |
| Outpatient procedure (facility) | 40% coinsurance after deductible |
| Outpatient procedure (physician) | 40% coinsurance after deductible |
| Physical rehabilitation | $50 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 40% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | $40 copay |
| Non-preferred Brand | $80 copay |
| Specialty | $250 copay |
Lab Tests and Diagnostic Procedures
| X-rays | $300 copay |
| Imaging (CT/PET/MRI) | 40% coinsurance after deductible |
| Blood work | $150 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $35 copay |
| Psychiatric hospital stay | 40% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.healthalliance.org/documents/sbc/IL_IND_PUB_SBC_2024_POS_4200_ELITE_SILVER/2024.pdf |
| Drug and medication plan formulary | https://healthalliance.org/documents/formulary/666/2024 |
| Search doctor list | https://www.healthalliance.org/Guests/ProviderSearch?DirectoryName=IEX |
