Prevea360 Silver Copay PCP 4500X (Free Virtual Care) – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$4,500 per person $4,500 per person
Out-of-pocket max	$8,850 per person $17,700 per family
Metal tier	Silver

Visit Copay

Primary care visit	$30 copay
Specialist visit	20% coinsurance after deductible
Preventive care visit	No data available

Urgent, Emergency Care, and Hospital Care

Urgent care	20% coinsurance after deductible
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	$30 copay

Maternitowny and Pregnancy

Well baby care	No data available
Labor, delivery, hospital stay	20% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$15 copay
Brand	20% coinsurance after deductible
Non-preferred Brand	20% coinsurance after deductible
Specialty	20% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	20% coinsurance after deductible
Imaging (CT/PET/MRI)	20% coinsurance 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://sbc.prevea360.com/api/GetPdfFile/true/Prevea360-Silver-Copay-PCP-4500X01_0124.PDF
Drug and medication plan formulary	https://www.prevea360.com/WIDrugList-2024
Search doctor list	https://www.prevea360.com/SearchPrevea360Network-2024