Complete Silver – EPO

Network type: EPO
Coverage tier: Silver
Primary care visit: $30 copay
Specialist visit: $60 copay
Urgent care visit: $60 copay

SKU: 34368KS0110009 Categories: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Description

Health Care Plan Details

Network type EPO
Deductible $6,000 per person $6,000 per person
Out-of-pocket max $8,500 per person $17,000 per family
Metal tier Silver

Visit Copay

Primary care visit $30 copay
Specialist visit $60 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $60 copay
Emergency room 40% coinsurance after deductible
Ambulance 40% coinsurance after deductible
Hospital stay (facility) 40% coinsurance after deductible
Hospital stay (physician) 40% coinsurance after deductible
Outpatient procedure (facility) 40% coinsurance after deductible
Outpatient procedure (physician) 40% coinsurance after deductible
Physical rehabilitation 40% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay 40% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic $3 copay
Brand $55 copay
Non-preferred Brand 50% coinsurance after deductible
Specialty 50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays 40% coinsurance after deductible
Imaging (CT/PET/MRI) 40% coinsurance after deductible
Blood work $30 copay

Mental and Psychiatric Health Care

Mental Health outpatient services $30 copay
Psychiatric hospital stay 40% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://api.centene.com/SBC/2024/34368KS0110009-01.pdf
Drug and medication plan formulary https://ambetter.sunflowerhealthplan.com/resources/pharmacy-resources.html
Search doctor list https://ambetter.sunflowerhealthplan.com/findadoc