Gold 1 On Exchange with Low Cost Generic Drugs – HMO

Network type: HMO
Coverage tier: Gold
Primary care visit: $20 copay
Specialist visit: $50 copay
Urgent care visit: $20 copay

SKU: 19722NM0010001 Categories: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Description

Health Care Plan Details

Network type HMO
Deductible $1,550 per person $1,550 per person
Out-of-pocket max $8,100 per person $16,200 per family
Metal tier Gold

Visit Copay

Primary care visit $20 copay
Specialist visit $50 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $20 copay
Emergency room 25% coinsurance
Ambulance 25% coinsurance
Hospital stay (facility) 25% after deductible
Hospital stay (physician) 25% after deductible
Outpatient procedure (facility) 25% after deductible
Outpatient procedure (physician) 25% after deductible
Physical rehabilitation $20 copay

Maternitowny and Pregnancy

Labor, delivery, hospital stay 25% after deductible

Pharmacy, Drugs, and Medication

Generic Share
Brand $50 copay after deductible
Non-preferred Brand 25% after deductible
Specialty 30% after deductible

Lab Tests and Diagnostic Procedures

X-rays 25% after deductible
Imaging (CT/PET/MRI) 25% after deductible
Blood work $15 copay

Mental and Psychiatric Health Care

Mental Health outpatient services No charge
Psychiatric hospital stay No charge

Health Plan Provider Information

Health Plan Benefits https://d2ed110nmrd591.cloudfront.net/blobs/Tz7dAwA5Bf19WcizUeLtow6f.pdf