Gold Elite Saver Plus – HMO

Network type: HMO
Coverage tier: Gold
Primary care visit: $10 copay
Specialist visit: $25 copay
Urgent care visit: $50 copay

Description

Health Care Plan Details

Network type HMO
Deductible $0 per person $0 per person
Out-of-pocket max $8,000 per person $16,000 per family
Metal tier Gold

Visit Copay

Primary care visit $10 copay
Specialist visit $25 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $50 copay
Emergency room $500 copay
Ambulance $500 copay
Hospital stay (facility) $1000 copay per Day
Hospital stay (physician) $200 copay
Outpatient procedure (facility) $500 copay
Outpatient procedure (physician) $200 copay
Physical rehabilitation $25 copay

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay $1,000 copay

Pharmacy, Drugs, and Medication

Generic $3 copay
Brand $75 copay after deductible
Non-preferred Brand $250 copay after deductible
Specialty $350 copay after deductible

Lab Tests and Diagnostic Procedures

X-rays $75 copay
Imaging (CT/PET/MRI) $375 copay
Blood work No charge

Mental and Psychiatric Health Care

Mental Health outpatient services $25 copay
Psychiatric hospital stay $1000 copay per Day

Health Plan Provider Information

Health Plan Benefits https://d3ul0st9g52g6o.cloudfront.net/2024/GA/sbc/2024_58081GA001003501.pdf
Drug and medication plan formulary https://www.hioscar.com/search-documents/drug-formularies/
Search doctor list https://www.hioscar.com/search/?networkId=025&year=2024