Non-Standard Low Gold: Tufts Health Direct Gold 1600 – HMO

Network type: HMO
Coverage tier: Gold
Primary care visit: $35 copay
Specialist visit: $55 copay
Urgent care visit: $55 copay

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Description

Health Care Plan Details

Network type HMO
Deductible $1,600 per person $1,600 per person
Out-of-pocket max $5,500 per person $11,000 per family
Metal tier Gold

Visit Copay

Primary care visit $35 copay
Specialist visit $55 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $55 copay
Emergency room $400 copay after deductible
Ambulance No charge after deductible
Hospital stay (facility) $750 copay after deductible
Hospital stay (physician) No charge after deductible
Outpatient procedure (facility) $500 copay after deductible
Outpatient procedure (physician) No charge after deductible
Physical rehabilitation $55 copay

Maternitowny and Pregnancy

Labor, delivery, hospital stay $750 copay after deductible

Pharmacy, Drugs, and Medication

Generic $25 copay
Brand $50 copay after deductible
Non-preferred Brand $125 copay after deductible
Specialty $125 copay after deductible

Lab Tests and Diagnostic Procedures

X-rays $75 copay after deductible
Imaging (CT/PET/MRI) $300 copay after deductible
Blood work $50 copay after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services $35 copay
Psychiatric hospital stay $750 copay after deductible

Health Plan Provider Information