Capital Health Plan HMO Silver 2102 (Wellness Program $$$) – HMO

Description

This plan has 87% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	HMO
Deductible	$750 per person $750 per person
Out-of-pocket max	$3,000 per person $6,000 per family
Metal tier	Silver

Visit Copay

Primary care visit	$20 copay
Specialist visit	$40 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$40 copay
Emergency room	25% coinsurance after deductible
Ambulance	$200 copay
Hospital stay (facility)	25% coinsurance after deductible
Hospital stay (physician)	25% coinsurance after deductible
Outpatient procedure (facility)	25% coinsurance after deductible
Outpatient procedure (physician)	25% coinsurance after deductible
Physical rehabilitation	25% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	25% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$15 copay
Brand	$50 copay
Non-preferred Brand	50% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	$20 copay
Imaging (CT/PET/MRI)	25% coinsurance after deductible
Blood work	No charge

Mental and Psychiatric Health Care

Mental Health outpatient services	$40 copay
Psychiatric hospital stay	25% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://capitalhealth.com/sites/default/files/uploaded-documents/Silver_2102.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