Freedom Silver 4000 – POS
Network type: POS
Coverage tier: Silver
Primary care visit: $40 copay
Specialist visit: $75 copay
Urgent care visit: $75 copay
Description
Health Care Plan Details
| Network type | POS |
| Deductible | $4,000 per person $4,000 per person |
| Out-of-pocket max | $8,400 per person $16,800 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $40 copay |
| Specialist visit | $75 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay |
| Emergency room | $550 copay after deductible |
| Ambulance | 30% coinsurance after deductible |
| Hospital stay (facility) | $1500 copay per Day after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | $1000 copay after deductible |
| Outpatient procedure (physician) | No charge after deductible |
| Physical rehabilitation | $40 copay after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $4500 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $20 copay |
| Brand | $60 copay after deductible |
| Non-preferred Brand | $100 copay after deductible |
| Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $300 copay after deductible |
| Imaging (CT/PET/MRI) | $300 copay after deductible |
| Blood work | No charge after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $40 copay |
| Psychiatric hospital stay | $1500 copay per Day after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://PrimewellHealth.com/documents/Marketplace/2024INDFreedomSilver4000SummaryOfBenefitsAndCoverage.pdf |
| Drug and medication plan formulary | https://PrimewellHealth.com/documents/Marketplace/2024CommercialAndExchangeMemberListOfCoveredDrugs(Formulary).pdf |
| Search doctor list | https://PrimewellHealth.com/provider/providersearch |
