Non-Standard Low Gold: WellSense Clarity Gold 1500 – HMO

Network type: HMO
Coverage tier: Gold
Primary care visit: $30 copay
Specialist visit: $55 copay
Urgent care visit: $55 copay

SKU: 82569MA0510001 Categories: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Description

Health Care Plan Details

Network type HMO
Deductible $1,500 per person $1,500 per person
Out-of-pocket max $5,250 per person $10,500 per family
Metal tier Gold

Visit Copay

Primary care visit $30 copay
Specialist visit $55 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $55 copay
Emergency room $250 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) $250 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 $30 copay
Brand $60 copay after deductible
Non-preferred Brand $90 copay after deductible
Specialty $90 copay after deductible

Lab Tests and Diagnostic Procedures

X-rays $75 copay after deductible
Imaging (CT/PET/MRI) $250 copay after deductible
Blood work $50 copay after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services $30 copay
Psychiatric hospital stay $750 copay after deductible

Health Plan Provider Information