Robin Select $3,600 Plus Silver – PPO

Network type: PPO
Coverage tier: Silver
Primary care visit: $25 copay after deductible, 20% coinsurance after deductible
Specialist visit: $25 copay after deductible, 20% coinsurance after deductible
Urgent care visit: $25 copay after deductible, 20% coinsurance after deductible

SKU: 20173WI0130033 Categories: Abrams, Algoma, Appleton, Bear Creek, Berlin, Big Falls, Black Creek, Bonduel, Bowler, Briggsville, Butte Des Morts, Caroline, Casco, Cecil, Clintonville, Coleman, Coloma, Combined Locks, Crivitz, Dale, De Pere, Embarrass, Endeavor, Fence, Florence, Forestville, Fremont, Gillett, Green Bay, Green Lake, Green Valley, Greenville, Gresham, Hancock, Hortonville, Kaukauna, Keshena, Kewaunee, Kimberly, King, Kingston, Krakow, Lakewood, Larsen, Lena, Leopolis, Little Chute, Little Suamico, Luxemburg, Manawa, Marion, Marquette, Mattoon, Menasha, Montello, Mountain, Neenah, Neopit, Neshkoro, New Franken, New London, Niagara, Nichols, Oconto, Oconto Falls, Ogdensburg, Omro, Oneida, Oshkosh, Oxford, Packwaukee, Peshtigo, Pickett, Pine River, Pound, Poy Sippi, Princeton, Pulaski, Redgranite, Ripon, Seymour, Shawano, Shiocton, Sobieski, Suamico, Suring, Tigerton, Tilleda, Townsend, Van Dyne, Waukau, Wautoma, Westfield, Weyauwega, Winnebago, Winneconne, Wisconsin, Wrightstown

Description

Description

Health Care Plan Details

Network type	PPO
Deductible	$3,600 per person $3,600 per person
Out-of-pocket max	$8,900 per person $17,800 per family
Metal tier	Silver

Visit Copay

Primary care visit	$25 copay after deductible, 20% coinsurance after deductible
Specialist visit	$25 copay after deductible, 20% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$25 copay after deductible, 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	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	$25 copay
Brand	20% coinsurance after deductible
Non-preferred Brand	20% coinsurance after deductible
Specialty	50% 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	20% coinsurance after deductible
Psychiatric hospital stay	20% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.healthpartners.com/content/dam/plan/sbc/hp/2024/wi-sbc-filing-only/ir660robinselect3600plussilver.pdf
Drug and medication plan formulary	https://healthpartners.com/preferredrx
Search doctor list	https://www.healthpartners.com/robin/selectind