Ascension Personalized Care Low Premium Silver – EPO

Description

This plan has 73% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	EPO
Deductible	$3,500 per person $3,500 per person
Out-of-pocket max	$7,250 per person $14,500 per family
Metal tier	Silver

Visit Copay

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

Urgent, Emergency Care, and Hospital Care

Urgent care	50% coinsurance after deductible
Emergency room	50% coinsurance after deductible
Ambulance	50% coinsurance after deductible
Hospital stay (facility)	50% coinsurance after deductible
Hospital stay (physician)	50% coinsurance after deductible
Outpatient procedure (facility)	50% coinsurance after deductible
Outpatient procedure (physician)	50% coinsurance after deductible
Physical rehabilitation	50% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$25 copay
Brand	$50 copay
Non-preferred Brand	50% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	50% coinsurance after deductible
Imaging (CT/PET/MRI)	50% coinsurance after deductible
Blood work	50% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$30 copay
Psychiatric hospital stay	50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.ascensionpersonalizedcare.com/-/media/members-home/member-resources/sbc/2024/tn/31663_low_premium_silver_73.pdf
Drug and medication plan formulary	https://www.ascensionpersonalizedcare.com/-/media/project/aca/aca/pharmacy/2024_drug_formulary.pdf
Search doctor list	https://www.ascensionpersonalizedcare.com/find-a-doctor