AvMed Entrust Platinum 25 Dental+Vision (2024) – HMO
Network type: HMO
Coverage tier: Platinum
Primary care visit: $10 copay
Specialist visit: $20 copay
Urgent care visit: $125 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $3,100 per person $6,200 per family |
| Metal tier | Platinum |
Visit Copay
| Primary care visit | $10 copay |
| Specialist visit | $20 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $125 copay |
| Emergency room | $100 copay |
| Ambulance | $200 copay |
| Hospital stay (facility) | $350 copay per Day |
| Hospital stay (physician) | No charge |
| Outpatient procedure (facility) | $200 copay |
| Outpatient procedure (physician) | No charge |
| Physical rehabilitation | $20 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $350 copay |
Pharmacy, Drugs, and Medication
| Generic | No charge |
| Brand | $20 copay |
| Non-preferred Brand | $60 copay |
| Specialty | 50% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | $10 copay |
| Imaging (CT/PET/MRI) | $100 copay |
| Blood work | No charge |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $10 copay |
| Psychiatric hospital stay | $350 copay per Day |
Health Plan Provider Information
| Health Plan Benefits | https://www.avmed.org/images/pdf/providers/patients/eligibility/AVINHP16090101240623.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= |
