Clear Cost Gold Plan – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $20 copay
Specialist visit: $60 copay
Urgent care visit: $60 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $3,000 per person $3,000 per person |
| Out-of-pocket max | $5,300 per person $10,600 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $20 copay |
| Specialist visit | $60 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $60 copay |
| Emergency room | $150 copay after deductible |
| Ambulance | $60 copay |
| Hospital stay (facility) | $150 copay after deductible |
| Hospital stay (physician) | $125 copay |
| Outpatient procedure (facility) | $125 copay |
| Outpatient procedure (physician) | $125 copay |
| Physical rehabilitation | $20 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $150 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $20 copay |
| Brand | $30 copay |
| Non-preferred Brand | $100 copay after deductible |
| Specialty | $75 copay |
Lab Tests and Diagnostic Procedures
| X-rays | $60 copay |
| Imaging (CT/PET/MRI) | $60 copay |
| Blood work | $60 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | No charge |
| Psychiatric hospital stay | No charge |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/8kh5DBsfBu6GT16xKXnUuC8H.pdf |
| Drug and medication plan formulary | https://client.formularynavigator.com/Search.aspx?siteCode=0334373670 |
