Jefferson Health Plans + Balanced Value + Silver + HMO + Off Exchange – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $45 copay
Specialist visit: $95 copay
Urgent care visit: $95 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | See brochure See brochure |
| Out-of-pocket max | N/A per person N/A per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $45 copay |
| Specialist visit | $95 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $95 copay |
| Emergency room | $950 copay |
| Ambulance | $200 copay |
| Hospital stay (facility) | first 5 day(s) $550 per day then $0 copay after deductible |
| Hospital stay (physician) | 10% after deductible |
| Outpatient procedure (facility) | $250 copay after deductible |
| Outpatient procedure (physician) | 10% after deductible |
| Physical rehabilitation | $100 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | first 5 day(s) $550 per day then $0 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $20 copay |
| Brand | 50% after deductible |
| Non-preferred Brand | 50% after deductible |
| Specialty | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $150 copay |
| Imaging (CT/PET/MRI) | $150 per procedure copay |
| Blood work | $300 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $95 copay |
| Psychiatric hospital stay | first 5 day(s) $550 per day then $0 copay after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/ohiByR9tgJPLJ3shxZGgc1Jy.pdf |
| Drug and medication plan formulary | https://www.jeffersonhealthplans.com/ |
