Non-Standard Low Gold: Complete HMO 1000 35% – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $25 copay
Specialist visit: $45 copay
Urgent care visit: $45 copay
Description
Health Care Plan Details
Network type | HMO |
Deductible | $1,000 per person $1,000 per person |
Out-of-pocket max | $7,900 per person $15,800 per family |
Metal tier | Gold |
Visit Copay
Primary care visit | $25 copay |
Specialist visit | $45 copay |
Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
Urgent care | $45 copay |
Emergency room | 35% after deductible |
Ambulance | No charge after deductible |
Hospital stay (facility) | 35% after deductible |
Hospital stay (physician) | 35% after deductible |
Outpatient procedure (facility) | 35% after deductible |
Outpatient procedure (physician) | 35% after deductible |
Physical rehabilitation | $45 copay |
Maternitowny and Pregnancy
Labor, delivery, hospital stay | 35% after deductible |
Pharmacy, Drugs, and Medication
Generic | $20 copay |
Brand | $50 copay |
Non-preferred Brand | 35% after deductible |
Specialty | 35% after deductible |
Lab Tests and Diagnostic Procedures
X-rays | $75 copay after deductible |
Imaging (CT/PET/MRI) | 35% after deductible |
Blood work | $50 copay after deductible |
Mental and Psychiatric Health Care
Mental Health outpatient services | $25 copay |
Psychiatric hospital stay | 35% after deductible |