Prestige Silver Essential + Dental + Vision + 3 Free PCP Visits – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$4,600 per person $4,600 per person
Out-of-pocket max	$9,100 per person $18,200 per family
Metal tier	Silver

Visit Copay

Primary care visit	$25 copay
Specialist visit	$80 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$80 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	$300 copay
Hospital stay (facility)	40% coinsurance after deductible
Hospital stay (physician)	40% coinsurance after deductible
Outpatient procedure (facility)	40% coinsurance after deductible
Outpatient procedure (physician)	40% coinsurance after deductible
Physical rehabilitation	40% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	40% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$20 copay
Brand	$80 copay
Non-preferred Brand	50% coinsurance after deductible
Specialty	40% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	$60 copay
Imaging (CT/PET/MRI)	40% coinsurance after deductible
Blood work	$30 copay

Mental and Psychiatric Health Care

Mental Health outpatient services	$25 copay
Psychiatric hospital stay	40% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://networkhealth.com/__assets/pdf/individual-benefits-2024/silverE.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