Jefferson Health Plans + $0 Deductible + Gold + HMO + On Exchange – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $25 copay
Specialist visit: $70 copay
Urgent care visit: $70 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | Success
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| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $25 copay |
| Specialist visit | $70 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $70 copay |
| Emergency room | $450 copay |
| Ambulance | $150 copay |
| Hospital stay (facility) | first 5 day(s) $350 per day then $0 copay |
| Hospital stay (physician) | No charge |
| Outpatient procedure (facility) | $150 copay |
| Outpatient procedure (physician) | No charge |
| Physical rehabilitation | $70 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | first 5 day(s) $350 per day then $0 copay |
Pharmacy, Drugs, and Medication
| Generic | $20 copay |
| Brand | $100 copay |
| Non-preferred Brand | 50% coinsurance |
| Specialty | 50% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | $80 copay |
| Imaging (CT/PET/MRI) | $80 per procedure copay |
| Blood work | $65 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $70 copay |
| Psychiatric hospital stay | first 5 day(s) $350 per day then $0 copay |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/XQ5yRar7UJCZhrByHwLbjQqg.pdf |
| Drug and medication plan formulary | https://www.jeffersonhealthplans.com/ |
