Complete Gold – HMO

Network type: HMO
Coverage tier: Gold
Primary care visit: $15 copay
Specialist visit: $35 copay
Urgent care visit: $35 copay

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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