Plus Silver – PPO
94% cost sharing reduction [Popular Plan]
Network type: PPO
Coverage tier: Silver
Primary care visit: $5 copay
Specialist visit: $35 copay
Urgent care visit: $50 copay
Description
This plan has 94% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | PPO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $1,000 per person $2,000 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $5 copay |
| Specialist visit | $35 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | 30% coinsurance |
| Ambulance | 30% coinsurance |
| Hospital stay (facility) | 20% coinsurance |
| Hospital stay (physician) | 20% coinsurance |
| Outpatient procedure (facility) | 20% coinsurance |
| Outpatient procedure (physician) | 20% coinsurance |
| Physical rehabilitation | $35 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 20% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | No charge |
| Brand | $20 copay |
| Non-preferred Brand | $100 copay |
| Specialty | $120 copay |
Lab Tests and Diagnostic Procedures
| X-rays | 30% coinsurance |
| Imaging (CT/PET/MRI) | 30% coinsurance |
| Blood work | 30% coinsurance |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $5 copay |
| Psychiatric hospital stay | 20% coinsurance |
Health Plan Provider Information
| Health Plan Benefits | https://mountainhealth.coop/wp-content/uploads/plans/2024/2024_IND_MT_PLUS_SILVER_94_SBC.pdf |
| Drug and medication plan formulary | https://cbg.adaptiverx.com/webSearch/index?key=8F02B26A288102C27BAC82D14C006C6FC54D480F80409B68BF3A93E5C825DF42 |
| Search doctor list | https://mountainhealth.coop/find-a-doctor/ |
