CareSource Marketplace Low Deductible Silver Dental, Vision, & Fitness – HMO

Network type: HMO
Coverage tier: Silver
Primary care visit: $30 copay
Specialist visit: $90 copay
Urgent care visit: $60 copay

SKU: 50328WV0020025 Categories: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Description

Health Care Plan Details

Network type HMO
Deductible Success

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Out-of-pocket max $9,200 per person $18,400 per family
Metal tier Silver

Visit Copay

Primary care visit $30 copay
Specialist visit $90 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $60 copay
Emergency room $500 copay after deductible
Ambulance 40% coinsurance after deductible
Hospital stay (facility) 40% coinsurance after deductible
Hospital stay (physician) No charge after deductible
Outpatient procedure (facility) 40% coinsurance after deductible
Outpatient procedure (physician) 40% coinsurance after deductible
Physical rehabilitation $30 copay

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay 40% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic $3 copay
Brand $75 copay
Non-preferred Brand 40% coinsurance after deductible
Specialty 50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays $200 copay after deductible
Imaging (CT/PET/MRI) $250 copay after deductible
Blood work $75 copay

Mental and Psychiatric Health Care

Mental Health outpatient services $30 copay
Psychiatric hospital stay 40% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://www.caresource.com/documents/Marketplace-2024-WV-LowDed-SilverBase-DVF-sum.pdf
Drug and medication plan formulary https://www.caresource.com/documents/Marketplace-2024-WV-formulary
Search doctor list https://www.caresource.com/Find-A-Doctor-WV-MP