Prestige Gold Essential + Dental + Vision + 3 Free PCP Visits – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $20 copay
Specialist visit: $60 copay
Urgent care visit: $60 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $1,750 per person $1,750 per person |
| Out-of-pocket max | $9,100 per person $18,200 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $20 copay |
| Specialist visit | $60 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $60 copay |
| 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 | $175 copay |
| 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 | 20% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 20% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $15 copay |
| Brand | $60 copay |
| Non-preferred Brand | 50% coinsurance after deductible |
| Specialty | 40% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $50 copay |
| Imaging (CT/PET/MRI) | 20% coinsurance after deductible |
| Blood work | $25 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $20 copay |
| Psychiatric hospital stay | 20% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://networkhealth.com/__assets/pdf/individual-benefits-2024/goldE.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 |
