Gold 80 Premier HMO – HMO

Network type: HMO
Coverage tier: Gold
Primary care visit: $35 copay
Specialist visit: $65 copay
Urgent care visit: $35 copay

Description

Health Care Plan Details

Network type HMO
Deductible $0 per person $0 per person
Out-of-pocket max $8,700 per person $17,400 per family
Metal tier Gold

Visit Copay

Primary care visit $35 copay
Specialist visit $65 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $35 copay
Emergency room $350 copay
Ambulance $250 copay
Hospital stay (facility) first 5 day(s) $330 per day then $0 copay
Hospital stay (physician) No charge
Outpatient procedure (facility) $130 copay
Outpatient procedure (physician) $40 copay
Physical rehabilitation $35 copay

Maternitowny and Pregnancy

Labor, delivery, hospital stay first 5 day(s) $330 per day then $0 copay

Pharmacy, Drugs, and Medication

Generic $15 copay
Brand $60 copay
Non-preferred Brand $85 copay
Specialty 20%, up to $250 copay, 20%, up to $250 coinsurance

Lab Tests and Diagnostic Procedures

X-rays $75 copay
Imaging (CT/PET/MRI) $75 copay
Blood work $40 copay

Mental and Psychiatric Health Care

Mental Health outpatient services $35 copay
Psychiatric hospital stay first 5 day(s) $330 per day then $0 copay

Health Plan Provider Information