First Choice Next Silver Premier 0 + No-Referrals Plan – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $55 copay
Specialist visit: $110 copay
Urgent care visit: $80 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $9,400 per person $18,800 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $55 copay |
| Specialist visit | $110 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $80 copay |
| Emergency room | 50% coinsurance |
| Ambulance | 50% coinsurance |
| Hospital stay (facility) | 50% coinsurance |
| Hospital stay (physician) | 50% coinsurance |
| Outpatient procedure (facility) | 50% coinsurance |
| Outpatient procedure (physician) | 50% coinsurance |
| Physical rehabilitation | $55 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 50% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | $35 copay |
| Brand | $200 copay |
| Non-preferred Brand | 50% coinsurance |
| Specialty | 50% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | 50% coinsurance |
| Imaging (CT/PET/MRI) | 50% coinsurance |
| Blood work | 50% coinsurance |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $55 copay |
| Psychiatric hospital stay | 50% coinsurance |
Health Plan Provider Information
| Health Plan Benefits | https://www.firstchoicenext.com/pdfs/2024/health-plans/forms/summary-of-benefits-sc-silver-premier-0-no-referrals.pdf |
| Drug and medication plan formulary | https://client.formularynavigator.com/Search.aspx?siteCode=7968260872 |
| Search doctor list | https://firstchoicenext.healthsparq.com/healthsparq/public/#/one/city=&state=&postalCode=&country=&insurerCode=FCNEXT_I&brandCode=FCNEXT&alphaPrefix=&bcbsaProductId=&productCode=SCEX |
