Clear Cost Silver Plan – Limited Service Area On – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $50 copay
Specialist visit: $100 copay
Urgent care visit: $100 copay
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 |
| 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/sFQWUPfjYUwg9C1u4cYmKp4P.pdf |
| Drug and medication plan formulary | https://client.formularynavigator.com/Search.aspx?siteCode=0334373670 |
