Peak $3,500 Plus Silver – PPO

Network type: PPO
Coverage tier: Silver
Primary care visit: first 3 visit(s) $0 then 20% after deductible copay, first 3 visit(s) $0 then 20% after deductible
Specialist visit: first 3 visit(s) $0 then 20% after deductible copay, first 3 visit(s) $0 then 20% after deductible
Urgent care visit: first 3 visit(s) $0 then 20% after deductible copay, first 3 visit(s) $0 then 20% after deductible

SKU: 79888MN0300003 Categories: Afton, Albany, Albertville, Andover, Annandale, Anoka, Avon, Bayport, Becker, Bethel, Big Lake, Buffalo, Burnsville, Carver, Cedar, Champlin, Chanhassen, Chaska, Circle Pines, Clear Lake, Clearwater, Cokato, Cold Spring, Collegeville, Cologne, Cottage Grove, Dayton, Delano, Eden Prairie, Elk River, Elko New Market, Elrosa, Excelsior, Farmington, Foley, Greenwald, Hamel, Hampton, Hanover, Hastings, Hopkins, Howard Lake, Hugo, Inver Grove Heights, Jordan, Lake Elmo, Lakeland, Lakeville, Long Lake, Loretto, Maple Grove, Maple Lake, Maple Plain, Marine On Saint Croix, Mayer, Melrose, Mendota, Minneapolis, Minnesota, Minnetonka, Monticello, Montrose, Mound, New Germany, New Munich, Newport, Norwood Young America, Osseo, Prior Lake, Randolph, Rice, Richmond, Rockford, Rockville, Rogers, Roscoe, Rosemount, Saint Bonifacius, Saint Cloud, Saint Joseph, Saint Martin, Saint Michael, Saint Paul, Saint Paul Park, Saint Stephen, Sartell, Sauk Rapids, Savage, Shakopee, South Saint Paul, Spring Park, Stillwater, Vermillion, Victoria, Waconia, Waite Park, Watertown, Waverly, Wayzata, Willernie, Young America

Description

Description

Health Care Plan Details

Network type	PPO
Deductible	$3,500 per person $3,500 per person
Out-of-pocket max	$9,450 per person $18,900 per family
Metal tier	Silver

Visit Copay

Primary care visit	first 3 visit(s) $0 then 20% after deductible copay, first 3 visit(s) $0 then 20% after deductible
Specialist visit	first 3 visit(s) $0 then 20% after deductible copay, first 3 visit(s) $0 then 20% after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	first 3 visit(s) $0 then 20% after deductible copay, first 3 visit(s) $0 then 20% after deductible
Emergency room	20% after deductible
Ambulance	20% after deductible
Hospital stay (facility)	20% after deductible
Hospital stay (physician)	20% after deductible
Outpatient procedure (facility)	20% after deductible
Outpatient procedure (physician)	20% after deductible
Physical rehabilitation	20% after deductible

Maternitowny and Pregnancy

Labor, delivery, hospital stay

20% after deductible

Pharmacy, Drugs, and Medication

Generic	$25 copay
Brand	20% after deductible
Non-preferred Brand	20% after deductible
Specialty	50% after deductible

Lab Tests and Diagnostic Procedures

X-rays	20% after deductible
Imaging (CT/PET/MRI)	20% after deductible
Blood work	20% after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	first 3 visit(s) $0 then 20% after deductible copay, first 3 visit(s) $0 then 20% after deductible
Psychiatric hospital stay	20% after deductible

Health Plan Provider Information