Capital Health Plan HMO Silver 2100 (Wellness Program $$$) – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $30 copay
Specialist visit: $60 copay
Urgent care visit: $60 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $5,800 per person $5,800 per person |
| Out-of-pocket max | $9,100 per person $18,200 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $30 copay |
| Specialist visit | $60 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $60 copay |
| Emergency room | 35% coinsurance after deductible |
| Ambulance | $400 copay |
| Hospital stay (facility) | 35% coinsurance after deductible |
| Hospital stay (physician) | 35% coinsurance after deductible |
| Outpatient procedure (facility) | 35% coinsurance after deductible |
| Outpatient procedure (physician) | 35% coinsurance after deductible |
| Physical rehabilitation | 35% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 35% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $35 copay |
| Brand | $75 copay |
| Non-preferred Brand | 50% coinsurance after deductible |
| Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $100 copay |
| Imaging (CT/PET/MRI) | 35% coinsurance after deductible |
| Blood work | No charge |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $60 copay |
| Psychiatric hospital stay | 35% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://capitalhealth.com/sites/default/files/uploaded-documents/Silver_2100_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 |
