Gold 80 Trio 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
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/FCzG9Xomfqniu8gCL2J5MKa1.pdf |
