Clear Cost Silver On Exchange – HMO

Network type: HMO
Coverage tier: Silver
Primary care visit: $50 copay
Specialist visit: $100 copay
Urgent care visit: $100 copay

SKU: 19722NM0010012 Categories: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Description

Health Care Plan Details

Network type HMO
Deductible $5,000 per person $5,000 per person
Out-of-pocket max $8,950 per person $17,900 per family
Metal tier Silver

Visit Copay

Primary care visit $50 copay
Specialist visit $100 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $100 copay
Emergency room $300 copay after deductible
Ambulance $100 copay
Hospital stay (facility) $300 copay after deductible
Hospital stay (physician) $300 copay after deductible
Outpatient procedure (facility) $300 copay
Outpatient procedure (physician) $300 copay
Physical rehabilitation $50 copay

Maternitowny and Pregnancy

Labor, delivery, hospital stay $300 copay after deductible

Pharmacy, Drugs, and Medication

Generic $35 copay
Brand $50 copay
Non-preferred Brand $250 copay after deductible
Specialty $100 copay

Lab Tests and Diagnostic Procedures

X-rays $100 copay
Imaging (CT/PET/MRI) $100 copay
Blood work $100 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/BD4dMew2JHHFNLLCFJHFhHw9.pdf