Connect 1500 Gold – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$1,500 per person $1,500 per person
Out-of-pocket max	$8,200 per person $16,400 per family
Metal tier	Gold

Visit Copay

Primary care visit	$30 copay
Specialist visit	$50 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$50 copay
Emergency room	$250 copay after deductible, 20% coinsurance after deductible
Ambulance	20% coinsurance after deductible
Hospital stay (facility)	20% coinsurance after deductible
Hospital stay (physician)	20% coinsurance after deductible
Outpatient procedure (facility)	20% coinsurance after deductible
Outpatient procedure (physician)	20% coinsurance after deductible
Physical rehabilitation	20% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	20% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$10 copay
Brand	$50 copay
Non-preferred Brand	50% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	20% coinsurance
Imaging (CT/PET/MRI)	20% coinsurance after deductible
Blood work	20% coinsurance

Mental and Psychiatric Health Care

Mental Health outpatient services	$30 copay
Psychiatric hospital stay	20% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://providencehealthplan.com/-/media/providence/website/pdfs/indi-fam/2024/SBC/OR/2024_Connect_1500_Gold_01.pdf
Drug and medication plan formulary	http://www.ProvidenceHealthPlan.com/2024FormularyN
Search doctor list	https://providencehealthplan.com/connectphppd