Ascension Personalized Care Low Premium Silver – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$4,000 per person $4,000 per person
Out-of-pocket max	$9,000 per person $18,000 per family
Metal tier	Silver

Visit Copay

Primary care visit	$40 copay
Specialist visit	$80 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	$40 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/tx/57125_low_premium_silver_on_exchange.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/tx-provider-directory