Prevea360 Silver Copay Plus 4800X (Free Virtual Care) – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $40 copay
Specialist visit: $80 copay
Urgent care visit: $40 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $4,800 per person $4,800 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $40 copay |
| Specialist visit | $80 copay |
| Preventive care visit | No data available |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $40 copay |
| Emergency room | $500 copay after deductible, 30% coinsurance after deductible |
| Ambulance | 30% coinsurance after deductible |
| Hospital stay (facility) | 30% coinsurance after deductible |
| Hospital stay (physician) | 30% coinsurance after deductible |
| Outpatient procedure (facility) | 30% coinsurance after deductible |
| Outpatient procedure (physician) | 30% coinsurance after deductible |
| Physical rehabilitation | $40 copay |
Maternitowny and Pregnancy
| Well baby care | No data available |
| Labor, delivery, hospital stay | 30% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $15 copay |
| Brand | $60 copay |
| Non-preferred Brand | 50% coinsurance |
| Specialty | 50% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | 30% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 30% coinsurance after deductible |
| Blood work | 30% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $40 copay |
| Psychiatric hospital stay | 30% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://sbc.prevea360.com/api/GetPdfFile/true/Prevea360-Silver-Copay-Plus-4800X01_0124.PDF |
| Drug and medication plan formulary | https://www.prevea360.com/WIDrugList-2024 |
| Search doctor list | https://www.prevea360.com/SearchPrevea360Network-2024 |
