BSW Elite Gold HMO 004 (Two free PCP visits, $0 Pediatric PCP visits) – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $40 copay
Specialist visit: $65 copay
Urgent care visit: $65 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $1,100 per person $1,100 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $40 copay |
| Specialist visit | $65 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $65 copay |
| Emergency room | $750 copay after deductible |
| Ambulance | $750 copay after deductible |
| Hospital stay (facility) | $1500 copay per Stay after deductible |
| Hospital stay (physician) | No charge |
| Outpatient procedure (facility) | $300 copay after deductible |
| Outpatient procedure (physician) | No charge |
| Physical rehabilitation | $40 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $1500 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $15 copay |
| Brand | $55 copay |
| Non-preferred Brand | $150 copay |
| Specialty | $500 copay |
Lab Tests and Diagnostic Procedures
| X-rays | 40% coinsurance after deductible |
| Imaging (CT/PET/MRI) | $300 copay after deductible |
| Blood work | 40% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $40 copay |
| Psychiatric hospital stay | $1500 copay per Stay after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.bswhealthplan.com/SiteCollectionDocuments/PlanDocs/2024/SBC/SWHP_2024_GHIW4M32_SBC.pdf |
| Drug and medication plan formulary | https://www.bswhealthplan.com/SiteCollectionDocuments/Formulary/Essential-Health-Benefits-Formulary-24.pdf |
| Search doctor list | https://portal.swhp.org/#/search?networkCode=PREM_HMO_INDV |
