Blue StandardHealth Silver 4 – HMO

Description

This plan has 73% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	HMO
Deductible	$5,700 per person $5,700 per person
Out-of-pocket max	$7,200 per person $14,400 per family
Metal tier	Silver

Visit Copay

Primary care visit	$40 copay
Specialist visit	$80 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$60 copay
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 copay

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	$80 copay after deductible
Specialty	$350 copay 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	$40 copay
Psychiatric hospital stay	40% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://common.secure.azblue.com/SBC/GetSBC?ProductName=StandardHealth%20Silver%204%20&Deductibles=5700&EffectiveDate=2024/01/01&ContractType=2.pdf
Drug and medication plan formulary	https://www.azblue.com/blueexchangestandardizedformulary
Search doctor list	https://www.azblue.com/maricopafocus