ENGAGE SILVER – POS
Network type: POS
Coverage tier: Silver
Primary care visit: $40 copay
Specialist visit: $75 copay after deductible
Urgent care visit: $110 copay
Description
Health Care Plan Details
| Network type | POS |
| Deductible | $5,700 per person $5,700 per person |
| Out-of-pocket max | $8,150 per person $16,300 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $40 copay |
| Specialist visit | $75 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $110 copay |
| Emergency room | 50% after deductible |
| Ambulance | 50% 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 | $75 copay after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 30% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 per script copay |
| Brand | $60 per script copay |
| Non-preferred Brand | $150 per script copay |
| Specialty | $200 per script copay |
Lab Tests and Diagnostic Procedures
| X-rays | 50% after deductible |
| Imaging (CT/PET/MRI) | 50% after deductible |
| Blood work | 50% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | first 1 visit(s) $0 then $40 copay |
| Psychiatric hospital stay | 30% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/uFnuhBtha9eAjukd1JCYbSbL.pdf |
| Drug and medication plan formulary | https://mountainhealth.coop/pharmacy/ |
