Complete Gold + Vision + Adult Dental – 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 | $1,450 per person $1,450 per person |
| Out-of-pocket max | $7,500 per person $15,000 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 | 20% after deductible |
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 | $15 copay |
| Psychiatric hospital stay | 20% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/ARxYNLag89XQkBmqWFgtorPW.pdf |
