Clear Cost Silver Plan – HMO

73% cost sharing reduction [Popular Plan]
Network type: HMO
Coverage tier: Silver
Primary care visit: $40 copay
Specialist visit: $90 copay
Urgent care visit: $90 copay

SKU: 39006NM001002204 Category:

Description

This plan has 73% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type HMO
Deductible $4,500 per person $4,500 per person
Out-of-pocket max $7,450 per person $14,900 per family
Metal tier Silver

Visit Copay

Primary care visit $40 copay
Specialist visit $90 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $90 copay
Emergency room $255 copay after deductible
Ambulance $90 copay
Hospital stay (facility) $255 copay after deductible
Hospital stay (physician) No charge
Outpatient procedure (facility) $250 copay
Outpatient procedure (physician) $250 copay
Physical rehabilitation $40 copay

Maternitowny and Pregnancy

Labor, delivery, hospital stay $255 copay after deductible

Pharmacy, Drugs, and Medication

Generic $30 copay
Brand $45 copay
Non-preferred Brand $205 copay after deductible
Specialty $95 copay

Lab Tests and Diagnostic Procedures

X-rays $90 copay
Imaging (CT/PET/MRI) $90 copay
Blood work $90 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/rW4zjaLr2LRGneWuvaGYtDMK.pdf
Search doctor list https://ambetter.westernskycommunitycare.com/findadoc