HMSA Gold PPO I – PPO
Network type: PPO
Coverage tier: Gold
Primary care visit: $30 copay
Specialist visit: $60 copay
Urgent care visit: $45 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $500 per person $500 per person |
| Out-of-pocket max | $8,700 per person $17,400 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $30 copay |
| Specialist visit | $60 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $45 copay |
| Emergency room | 20% coinsurance after deductible |
| Ambulance | 20% coinsurance after deductible |
| Hospital stay (facility) | 20% coinsurance after deductible |
| Hospital stay (physician) | 20% coinsurance after deductible |
| Outpatient procedure (facility) | 20% coinsurance after deductible |
| Outpatient procedure (physician) | 20% coinsurance after deductible |
| Physical rehabilitation | $30 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 20% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $15 copay |
| Brand | $30 copay |
| Non-preferred Brand | $50 copay |
| Specialty | $200 copay |
Lab Tests and Diagnostic Procedures
| X-rays | 20% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 20% coinsurance after deductible |
| Blood work | 20% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $30 copay |
| Psychiatric hospital stay | 20% coinsurance |
Health Plan Provider Information
| Health Plan Benefits | https://hmsa.com/sbc/2024/gold-ppo-i.pdf |
| Drug and medication plan formulary | https://prc.hmsa.com/s/article/HMSA-s-Metallic-Drug-Formulary-and-Coverage-Codes |
| Search doctor list | https://hmsa.com/search/providers |
