Prestige Gold 50 + Dental + Vision + 1 Free PCP Visit – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$1,000 per person $1,000 per person
Out-of-pocket max	$4,300 per person $8,600 per family
Metal tier	Gold

Visit Copay

Primary care visit	50% coinsurance after deductible
Specialist visit	50% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	50% coinsurance after deductible
Emergency room	An urgent care center can be a convenient option if you have a non-life-threatening injury and your doctor is not available.
Ambulance	50% coinsurance after deductible
Hospital stay (facility)	50% coinsurance after deductible
Hospital stay (physician)	50% coinsurance after deductible
Outpatient procedure (facility)	50% coinsurance after deductible
Outpatient procedure (physician)	50% coinsurance after deductible
Physical rehabilitation	50% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$15 copay
Brand	$50 copay
Non-preferred Brand	50% coinsurance after deductible
Specialty	40% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	50% coinsurance after deductible
Imaging (CT/PET/MRI)	50% coinsurance after deductible
Blood work	50% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	50% coinsurance after deductible
Psychiatric hospital stay	50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://networkhealth.com/__assets/pdf/individual-benefits-2024/gold50.pdf
Drug and medication plan formulary	https://www.networkhealth.com/__assets/pdf/pharmacy-drug-lists/2024individualdruglist5tier.pdf
Search doctor list	https://www.networkhealth.com/find-a-doctor-prestige