Passage SOLO HMO Copay/Coins. $7,500 ded. – HMO
Network type: HMO
Coverage tier: Expanded Bronze
Primary care visit: $40 copay
Specialist visit: $60 copay after deductible
Urgent care visit: $100 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | N/A N/A |
| Out-of-pocket max | N/A per person N/A per family |
| Metal tier | Expanded Bronze |
Visit Copay
| Primary care visit | $40 copay |
| Specialist visit | $60 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $100 copay |
| Emergency room | 50% after deductible |
| Ambulance | 50% after deductible |
| Hospital stay (facility) | 50% after deductible |
| Hospital stay (physician) | 50% after deductible |
| Outpatient procedure (facility) | 50% after deductible |
| Outpatient procedure (physician) | 50% after deductible |
| Physical rehabilitation | 50% after deductible |
Maternitowny and Pregnancy
Pharmacy, Drugs, and Medication
| Generic | $15 per script copay |
| Brand | $60 per script after deductible copay |
| Non-preferred Brand | 50% after deductible, up to $500 per script copay, 50% after deductible, up to $500 per script |
| Specialty | 50% after deductible, up to $500 per script copay, 50% after deductible, up to $500 per script |
Lab Tests and Diagnostic Procedures
| X-rays | $60 per procedure after deductible copay |
| Imaging (CT/PET/MRI) | 50% after deductible |
| Blood work | $20 per procedure after deductible copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $60 copay |
| Psychiatric hospital stay | 50% after deductible |
