Ascension Personalized Care Low Premium Silver – EPO
87% cost sharing reduction [Popular Plan]
Network type: EPO
Coverage tier: Silver
Primary care visit: $10 copay
Specialist visit: $20 copay
Urgent care visit: 50% coinsurance after deductible
Description
This plan has 87% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | EPO |
| Deductible | $1,000 per person $1,000 per person |
| Out-of-pocket max | $2,100 per person $4,200 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $10 copay |
| Specialist visit | $20 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | 50% coinsurance after deductible |
| 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 | 40% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 40% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $20 copay |
| Brand | $40 copay |
| Non-preferred Brand | 50% coinsurance after deductible |
| Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 40% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 40% coinsurance after deductible |
| Blood work | 40% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $10 copay |
| Psychiatric hospital stay | 40% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.ascensionpersonalizedcare.com/-/media/members-home/member-resources/sbc/2024/ks/32542_low_premium_silver_87.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 |
