Gold 1770 (Low Primary Care, Specialist & Urgent Care Copay, Open Access) – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $20 copay
Specialist visit: $50 copay
Urgent care visit: $60 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $1,600 per person $1,600 per person |
| Out-of-pocket max | $8,700 per person $17,400 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 | $60 copay |
| Emergency room | 20% coinsurance after deductible |
| Ambulance | 20% coinsurance after deductible |
| Hospital stay (facility) | 20% coinsurance after deductible |
| Hospital stay (physician) | 20% coinsurance after deductible |
| Outpatient procedure (facility) | 20% coinsurance after deductible |
| Outpatient procedure (physician) | 20% coinsurance after deductible |
| Physical rehabilitation | 20% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 20% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | $40 copay |
| Non-preferred Brand | $75 copay |
| Specialty | 30% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | 20% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 20% coinsurance after deductible |
| Blood work | 20% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 20% coinsurance after deductible |
| Psychiatric hospital stay | 20% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://hf.org/2024_sbc_1770.pdf |
| Drug and medication plan formulary | https://hf.org/MP_formulary_2024 |
| Search doctor list | https://hf.org/MP_directory_2024 |
