CareSource Marketplace Low Premium Silver Dental, Vision, & Fitness – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $30 copay
Specialist visit: $70 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $6,500 per person $6,500 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 | $70 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $500 copay after deductible |
| Ambulance | 50% coinsurance after deductible |
| Hospital stay (facility) | $500 copay per Stay after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | 50% coinsurance after deductible |
| Outpatient procedure (physician) | 50% coinsurance after deductible |
| Physical rehabilitation | $30 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $500 copay 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 | $40 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $30 copay |
| Psychiatric hospital stay | $500 copay per Stay after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.caresource.com/documents/Marketplace-2024-NC-LowPrem-SilverBase-DVF-sum.pdf |
| Drug and medication plan formulary | https://www.caresource.com/documents/Marketplace-2024-NC-formulary |
| Search doctor list | https://www.caresource.com/Find-A-Doctor-NC-MP |
