HMO Silver 7500 – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $40 copay
Specialist visit: $80 copay
Urgent care visit: $60 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $7,500 per person $7,500 per person |
| Out-of-pocket max | $8,400 per person $16,800 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $40 copay |
| Specialist visit | $80 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $60 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 | $40 copay |
Maternitowny and Pregnancy
| Well baby care | $40 copay |
| Labor, delivery, hospital stay | 30% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $20 copay |
| Brand | $40 copay |
| Non-preferred Brand | $80 copay after deductible |
| Specialty | $350 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 | $40 copay |
| Psychiatric hospital stay | 30% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.aspirushealthplan.com/group-individual/files/sbcs/2024/86584WI0010001-01.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 |
