ENGAGE GOLD – POS
Network type: POS
Coverage tier: Gold
Primary care visit: $30 copay
Specialist visit: $50 copay
Urgent care visit: $75 copay
Description
Health Care Plan Details
| Network type | POS |
| Deductible | $1,000 per person $1,000 per person |
| Out-of-pocket max | $6,500 per person $13,000 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 | $75 copay |
| Emergency room | 40% after deductible |
| Ambulance | 40% after deductible |
| Hospital stay (facility) | 30% after deductible |
| Hospital stay (physician) | 30% after deductible |
| Outpatient procedure (facility) | 30% after deductible |
| Outpatient procedure (physician) | 30% after deductible |
| Physical rehabilitation | $50 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 30% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $5 per script copay |
| Brand | $40 per script copay |
| Non-preferred Brand | $100 per script copay |
| Specialty | $150 per script copay |
Lab Tests and Diagnostic Procedures
| X-rays | 40% after deductible |
| Imaging (CT/PET/MRI) | 40% after deductible |
| Blood work | 40% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | first 1 visit(s) $0 then $30 copay |
| Psychiatric hospital stay | 30% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/3V1PmZ5WugiH5WpnZFQvTbv4.pdf |
| Drug and medication plan formulary | https://mountainhealth.coop/pharmacy/ |
