High Plains Gold – PPO
Network type: PPO
Coverage tier: Gold
Primary care visit: $30 copay
Specialist visit: $50 copay
Urgent care visit: $75 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $1,000 per person $1,000 per person |
| Out-of-pocket max | $6,500 per person $13,000 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $30 copay |
| Specialist visit | $50 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay |
| Emergency room | 40% coinsurance after deductible |
| Ambulance | 40% 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 | $50 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 30% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $5 copay |
| Brand | $40 copay |
| Non-preferred Brand | $100 copay |
| Specialty | $150 copay |
Lab Tests and Diagnostic Procedures
| X-rays | 40% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 40% coinsurance after deductible |
| Blood work | 40% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $30 copay |
| Psychiatric hospital stay | 30% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://mountainhealth.coop/wp-content/uploads/plans/2024/2024_WY_IND_HIGH_PLAINS_GOLD_SBC.pdf |
| Drug and medication plan formulary | https://cbg.adaptiverx.com/webSearch/index?key=8F02B26A288102C27BAC82D14C006C6FC54D480F80409B68BF3A93E5C825DF42 |
| Search doctor list | https://mhc.healthtrioconnect.com/public-app/consumer/provdir/entry.page |
