Gold Value 1819 ($1,300 Tier 1 Medical Deductible, High Value Network Savings, Open Access) – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $15 copay
Specialist visit: $30 copay
Urgent care visit: $30 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | Success
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| Out-of-pocket max | $7,800 per person $15,600 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $15 copay |
| Specialist visit | $30 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $30 copay |
| Emergency room | 30% coinsurance after deductible |
| Ambulance | 30% coinsurance after deductible |
| Hospital stay (facility) | 30% coinsurance after deductible |
| Hospital stay (physician) | 30% coinsurance after deductible |
| Outpatient procedure (facility) | 30% coinsurance after deductible |
| Outpatient procedure (physician) | 30% coinsurance after deductible |
| Physical rehabilitation | 30% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 30% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $15 copay |
| Brand | $30 copay after deductible |
| Non-preferred Brand | $55 copay after deductible |
| Specialty | 25% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 30% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 30% coinsurance after deductible |
| Blood work | No charge |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 30% coinsurance after deductible |
| Psychiatric hospital stay | 30% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://hf.org/2024_sbc_1819.pdf |
| Drug and medication plan formulary | https://hf.org/MP_formulary_2024 |
| Search doctor list | https://hf.org/MP_directory_2024 |
