Focused Silver with Atrium Health + Vision + Adult Dental – HMO

Network type: HMO
Coverage tier: Silver
Primary care visit: $45 copay
Specialist visit: $100 copay
Urgent care visit: $60 copay

Description

Health Care Plan Details

Network type HMO
Deductible $6,300 per person $6,300 per person
Out-of-pocket max $8,000 per person $16,000 per family
Metal tier Silver

Visit Copay

Primary care visit $45 copay
Specialist visit $100 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $60 copay
Emergency room 50% coinsurance after deductible
Ambulance 50% coinsurance after deductible
Hospital stay (facility) 50% coinsurance after deductible
Hospital stay (physician) 50% coinsurance after deductible
Outpatient procedure (facility) 50% coinsurance after deductible
Outpatient procedure (physician) 50% coinsurance after deductible
Physical rehabilitation 50% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay 50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic $3 copay
Brand $75 copay
Non-preferred Brand 50% coinsurance after deductible
Specialty 50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays 50% coinsurance after deductible
Imaging (CT/PET/MRI) 50% coinsurance after deductible
Blood work $50 copay

Mental and Psychiatric Health Care

Mental Health outpatient services $45 copay
Psychiatric hospital stay 50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://api.centene.com/SBC/2024/77264NC0020051-01.pdf
Drug and medication plan formulary https://ambetterofnorthcarolina.com/resources/pharmacy-resources.html
Search doctor list https://ambetterofnorthcarolina.com/findadoc