Physicians Health Plan HMO Exclusive Gold Classic – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $30 copay
Specialist visit: $50 copay
Urgent care visit: $75 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $1,000 per person $1,000 per person |
| Out-of-pocket max | $8,000 per person $16,000 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $30 copay |
| Specialist visit | $50 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay |
| Emergency room | 20% coinsurance after deductible |
| Ambulance | 20% coinsurance after deductible |
| Hospital stay (facility) | 20% coinsurance after deductible |
| Hospital stay (physician) | 20% coinsurance after deductible |
| Outpatient procedure (facility) | 20% coinsurance after deductible |
| Outpatient procedure (physician) | 20% coinsurance after deductible |
| Physical rehabilitation | $50 copay after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 20% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $20 copay |
| Brand | $60 copay |
| Non-preferred Brand | $80 copay |
| Specialty | 20% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | 20% coinsurance after deductible |
| Imaging (CT/PET/MRI) | $150 copay after deductible |
| Blood work | 20% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $30 copay |
| Psychiatric hospital stay | 20% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.phpmichigan.com/upload/docs/ChoosePHPMI/SBCs/2024Plans/PHP_Excl_Gold_Classic_OnMP_60829MI0190009-01_2024SBC_GNN010_RX08E552.pdf |
| Drug and medication plan formulary | https://www.phpmichigan.com/upload/docs/Providers/Pharmacy/Prescription-Drug-List-6-Tier-2024.pdf |
| Search doctor list | https://www.phpmichigan.com/upload/docs/Directories/2023/Exclusive%20Provider%20Directory%2008%2025%202023.pdf |
