Non-Standard Low Gold: Community Care Connector Low Gold – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $35 copay
Specialist visit: $50 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $2,000 per person $2,000 per person |
| Out-of-pocket max | $6,000 per person $12,000 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $35 copay |
| Specialist visit | $50 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $200 copay |
| Ambulance | No charge after deductible |
| Hospital stay (facility) | $750 copay after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | $750 copay after deductible |
| Outpatient procedure (physician) | No charge after deductible |
| Physical rehabilitation | $50 copay after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $750 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $30 copay |
| Brand | $60 copay |
| Non-preferred Brand | $100 copay after deductible |
| Specialty | $100 copay after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $60 copay |
| Imaging (CT/PET/MRI) | $450 copay after deductible |
| Blood work | $60 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $35 copay |
| Psychiatric hospital stay | $750 copay after deductible |
