Ascension Personalized Care No Deductible Silver – EPO
Network type: EPO
Coverage tier: Silver
Primary care visit: $30 copay
Specialist visit: $60 copay
Urgent care visit: $100 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | Success
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| Out-of-pocket max | $9,450 per person $18,900 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 | $100 copay |
| Emergency room | $1,500 copay |
| Ambulance | $1,500 copay |
| Hospital stay (facility) | 40% coinsurance |
| Hospital stay (physician) | 40% coinsurance |
| Outpatient procedure (facility) | $1,500 copay |
| Outpatient procedure (physician) | $100 copay |
| Physical rehabilitation | $100 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 40% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | $30 copay |
| Brand | $100 copay |
| Non-preferred Brand | 50% coinsurance |
| Specialty | 50% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | $200 copay |
| Imaging (CT/PET/MRI) | $200 copay |
| Blood work | $100 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $30 copay |
| Psychiatric hospital stay | 40% coinsurance |
Health Plan Provider Information
| Health Plan Benefits | https://www.ascensionpersonalizedcare.com/-/media/members-home/member-resources/sbc/2024/in/35755_no_deductible_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/find-a-doctor |
