Community Health Plan of Washington Cascade Select Silver – EPO
Network type: EPO
Coverage tier: Silver
Primary care visit: first 2 visit(s) $0 then $30 copay
Specialist visit: first 2 visit(s) $0 then $65 copay
Urgent care visit: first 2 visit(s) $0 then $65 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $2,500 per person $2,500 per person |
| Out-of-pocket max | $9,200 per person $18,400 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | first 2 visit(s) $0 then $30 copay |
| Specialist visit | first 2 visit(s) $0 then $65 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | first 2 visit(s) $0 then $65 copay |
| Emergency room | $800 copay after deductible |
| Ambulance | $375 copay |
| Hospital stay (facility) | first 5 day(s) $800 per day then $0 copay after deductible |
| Hospital stay (physician) | No charge |
| Outpatient procedure (facility) | $600 copay after deductible |
| Outpatient procedure (physician) | $200 copay after deductible |
| Physical rehabilitation | $40 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | first 5 day(s) $800 per day then $0 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $25 copay |
| Brand | $75 copay |
| Non-preferred Brand | $250 copay after deductible |
| Specialty | $250 copay after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $65 copay |
| Imaging (CT/PET/MRI) | 30% after deductible |
| Blood work | $40 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | first 2 visit(s) $0 then $30 copay |
| Psychiatric hospital stay | first 5 day(s) $800 per day then $0 copay after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/wJsKwx33eT4YkbR7cbqeEhYx.pdf |
