Personal Choice PPO Silver Classic – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: $30 copay
Specialist visit: $75 copay
Urgent care visit: 30% after deductible
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $3,500 per person $3,500 per person |
| Out-of-pocket max | $8,500 per person $17,000 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $30 copay |
| Specialist visit | $75 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | 30% after deductible |
| Emergency room | 30% after deductible |
| Ambulance | 30% after deductible |
| Hospital stay (facility) | 25% after deductible |
| Hospital stay (physician) | 30% after deductible |
| Outpatient procedure (facility) | 30% after deductible |
| Outpatient procedure (physician) | 30% after deductible |
| Physical rehabilitation | $75 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 25% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $20 copay |
| Brand | 50% after deductible |
| Non-preferred Brand | 50% after deductible |
| Specialty | 50% after deductible, up to $1,000 copay, 50% after deductible, up to $1,000 |
Lab Tests and Diagnostic Procedures
| X-rays | 30% after deductible |
| Imaging (CT/PET/MRI) | 30% after deductible |
| Blood work | No charge |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $75 copay |
| Psychiatric hospital stay | 25% after deductible |
