Market HMO 4000 HSA – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$4,000 per person $4,000 per person
Out-of-pocket max	$5,850 per person $11,700 per family
Metal tier	Silver

Visit Copay

Primary care visit	30% coinsurance after deductible
Specialist visit	30% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	30% coinsurance after deductible
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	30% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	30% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	No charge
Brand	30% coinsurance after deductible
Non-preferred Brand	This is the amount you will pay for a brand name drug prescription.
Specialty	30% coinsurance 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	30% coinsurance after deductible
Psychiatric hospital stay	30% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.medmutual.com/-/media/13C1B64D2F61485EAE9B3769AF2CCD78.pdf
Drug and medication plan formulary	https://www.medmutual.com/2024Drugs
Search doctor list	https://providersearch.medmutual.com/