Capital Health Plan HMO Gold 3000 (Wellness Program $$$) – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $25 copay
Specialist visit: $50 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $7,900 per person $15,800 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $25 copay |
| Specialist visit | $50 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $350 copay |
| Ambulance | $200 copay |
| Hospital stay (facility) | $750 copay per Day |
| Hospital stay (physician) | No charge |
| Outpatient procedure (facility) | $350 copay |
| Outpatient procedure (physician) | $100 copay |
| Physical rehabilitation | $50 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $750 copay |
Pharmacy, Drugs, and Medication
| Generic | $15 copay |
| Brand | $30 copay |
| Non-preferred Brand | $60 copay |
| Specialty | $250 copay |
Lab Tests and Diagnostic Procedures
| X-rays | No charge |
| Imaging (CT/PET/MRI) | $250 copay |
| Blood work | No charge |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $50 copay |
| Psychiatric hospital stay | $750 copay |
Health Plan Provider Information
| Health Plan Benefits | https://capitalhealth.com/sites/default/files/uploaded-documents/Gold_3000_OnEx.pdf |
| Drug and medication plan formulary | http://www.myprime.com/content/dam/prime/memberportal/WebDocs/2024/Formularies/HIM/2024_CHP_6T_NR_Formulary.pdf |
| Search doctor list | https://capitalhealth.com/directories/provider-directory |
