Clear Choice PPO Gold 2500 – PPO
Network type: PPO
Coverage tier: Gold
Primary care visit: $20 copay
Specialist visit: $50 copay
Urgent care visit: $40 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | See brochure See brochure |
| Out-of-pocket max | N/A per person N/A per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $20 copay |
| Specialist visit | $50 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $40 copay |
| Emergency room | 30% after deductible |
| Ambulance | 30% after deductible |
| Hospital stay (facility) | 30% after deductible |
| Hospital stay (physician) | 30% after deductible |
| Outpatient procedure (facility) | 30% after deductible |
| Outpatient procedure (physician) | 30% after deductible |
| Physical rehabilitation | $30 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 30% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $5 per script copay |
| Brand | $50 per script copay |
| Non-preferred Brand | 30%, up to $300 per script copay, 30%, up to $300 per script coinsurance |
| Specialty | 30%, up to $300 per script copay, 30%, up to $300 per script coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | 30% after deductible |
| Imaging (CT/PET/MRI) | $250 copay |
| Blood work | $15 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | first 1 visit(s) $0 then $20 copay |
| Psychiatric hospital stay | 30% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/p2MBPerkdb7kX8tCSKZG5F5g.pdf |
| Drug and medication plan formulary | https://www.harvardpilgrim.org/2024Value5T |