HMO Silver 700 CSR 87 – HMO

Description

This plan has 87% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	HMO
Deductible	$700 per person $700 per person
Out-of-pocket max	$3,000 per person $6,000 per family
Metal tier	Silver

Visit Copay

Primary care visit	$20 copay
Specialist visit	$40 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	$20 copay

Maternitowny and Pregnancy

Well baby care	$20 copay
Labor, delivery, hospital stay	30% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$10 copay
Brand	$20 copay
Non-preferred Brand	$60 copay after deductible
Specialty	$250 copay after deductible

Lab Tests and Diagnostic Procedures

X-rays	30% coinsurance after deductible
Imaging (CT/PET/MRI)	30% coinsurance after deductible
Blood work	30% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$20 copay
Psychiatric hospital stay	30% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.aspirushealthplan.com/group-individual/files/sbcs/2024/86584WI0010012-05.pdf
Drug and medication plan formulary	https://www.aspirushealthplan.com/group-individual/Aspirus_Drug_Formulary/AspirusDrugFormulary2023.PDF
Search doctor list	https://p1.aspirushealthplan.com/find-a-doctor