Atlas $3,000 w/Copay P-S Silver – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: $25 copay
Specialist visit: $75 copay
Urgent care visit: $75 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $3,000 per person $3,000 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $25 copay |
| Specialist visit | $75 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay |
| Emergency room | 25% coinsurance after deductible |
| Ambulance | 25% coinsurance after deductible |
| Hospital stay (facility) | 25% coinsurance after deductible |
| Hospital stay (physician) | 25% coinsurance after deductible |
| Outpatient procedure (facility) | 25% coinsurance after deductible |
| Outpatient procedure (physician) | 25% coinsurance after deductible |
| Physical rehabilitation | $75 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 25% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $25 copay |
| Brand | 25% coinsurance after deductible |
| Non-preferred Brand | 25% coinsurance after deductible |
| Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 25% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 25% coinsurance after deductible |
| Blood work | 25% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $25 copay |
| Psychiatric hospital stay | 25% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.healthpartners.com/content/dam/plan/sbc/hp/2024/wi-sbc-filing-only/iw638atlas3000wcopaypssilver.pdf |
| Drug and medication plan formulary | https://healthpartners.com/preferredrx |
| Search doctor list | https://www.healthpartners.com/atlasnetwork |
