Gold Elite Saver Plus – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: No charge
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 | $7,900 per person $15,800 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | No charge |
| 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) | first 3 day(s) $1,000 per day then $0 copay |
| Hospital stay (physician) | $200 copay |
| Outpatient procedure (facility) | $500 copay |
| Outpatient procedure (physician) | $200 copay |
| Physical rehabilitation | $25 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | first 3 day(s) $1,000 per day then $0 copay |
Pharmacy, Drugs, and Medication
| Generic | $3 copay |
| Brand | $75 copay after deductible |
| Non-preferred Brand | $250 copay after deductible |
| Specialty | $550 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 | No charge |
| Psychiatric hospital stay | first 3 day(s) $1,000 per day then $0 copay |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/SZUpq9orEAArjF7iXEmBepoa.pdf |
