AvMed Entrust Gold 125 Dental+Vision (2024) – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $35 copay
Specialist visit: $70 copay
Urgent care visit: $125 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $2,000 per person $2,000 per person |
| Out-of-pocket max | $4,700 per person $9,400 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $35 copay |
| Specialist visit | $70 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $125 copay |
| Emergency room | $500 copay after deductible |
| Ambulance | $200 copay |
| Hospital stay (facility) | $850 copay per Stay after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | $650 copay after deductible |
| Outpatient procedure (physician) | No charge after deductible |
| Physical rehabilitation | $70 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $850 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $15 copay |
| Brand | $60 copay |
| Non-preferred Brand | $120 copay |
| Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $75 copay |
| Imaging (CT/PET/MRI) | $250 copay |
| Blood work | $10 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $35 copay |
| Psychiatric hospital stay | $850 copay per Stay after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.avmed.org/images/pdf/providers/patients/eligibility/AVINHG16120101240623.pdf |
| Drug and medication plan formulary | https://www.avmed.org/media/li3fglxe/2024-individual-and-family-plan-formulary-non-standard.pdf |
| Search doctor list | https://avmed.sapphirecareselect.com/?network_id=112&ci=AVMED&geo_location= |
