Complete Silver + Vision + Adult Dental – HMO
87% cost sharing reduction [Popular Plan]
Network type: HMO
Coverage tier: Silver
Primary care visit: $15 copay
Specialist visit: $45 copay
Urgent care visit: $10 copay
Description
This plan has 87% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | HMO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $3,150 per person $6,300 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $15 copay |
| Specialist visit | $45 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $10 copay |
| Emergency room | 40% coinsurance |
| Ambulance | 40% coinsurance |
| Hospital stay (facility) | 40% coinsurance |
| Hospital stay (physician) | 40% coinsurance |
| Outpatient procedure (facility) | 40% coinsurance |
| Outpatient procedure (physician) | 40% coinsurance |
| Physical rehabilitation | 40% coinsurance |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 40% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | $3 copay |
| Brand | $40 copay |
| Non-preferred Brand | 50% coinsurance |
| Specialty | 50% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | 40% coinsurance |
| Imaging (CT/PET/MRI) | 40% coinsurance |
| Blood work | $25 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $15 copay |
| Psychiatric hospital stay | 40% coinsurance |
Health Plan Provider Information
| Health Plan Benefits | https://api.centene.com/SBC/2024/70893GA0030017-05.pdf |
| Drug and medication plan formulary | https://ambetter.pshpgeorgia.com/resources/pharmacy-resources.html |
| Search doctor list | https://ambetter.pshpgeorgia.com/findadoc |
