Complete Gold – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $15 copay
Specialist visit: $35 copay
Urgent care visit: $35 copay
Description
Health Care Plan Details
Network type | HMO |
Deductible | $1,850 per person $1,850 per person |
Out-of-pocket max | $7,850 per person $15,700 per family |
Metal tier | Gold |
Visit Copay
Primary care visit | $15 copay |
Specialist visit | $35 copay |
Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
Urgent care | $35 copay |
Emergency room | 20% after deductible |
Ambulance | 20% after deductible |
Hospital stay (facility) | 20% after deductible |
Hospital stay (physician) | 20% after deductible |
Outpatient procedure (facility) | 20% after deductible |
Outpatient procedure (physician) | 20% after deductible |
Physical rehabilitation | $15 copay |
Maternitowny and Pregnancy
Labor, delivery, hospital stay | 20% after deductible |
Pharmacy, Drugs, and Medication
Generic | $3 copay |
Brand | $30 copay |
Non-preferred Brand | 30% after deductible |
Specialty | 30% after deductible |
Lab Tests and Diagnostic Procedures
X-rays | 20% after deductible |
Imaging (CT/PET/MRI) | 20% after deductible |
Blood work | $15 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/c6iPmWxjvQFsKAMpMqaPdx3k.pdf |
Search doctor list | https://ambetter.westernskycommunitycare.com/findadoc |