Select Gold 2500 Ded/5000 MOOP Primary Care Preferred with Vision – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: No charge
Specialist visit: $125 copay
Urgent care visit: No charge
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $2,500 per person $2,500 per person |
| Out-of-pocket max | $5,000 per person $10,000 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | No charge |
| Specialist visit | $125 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | No charge |
| 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 | No charge |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 20% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $20 copay |
| Brand | $35 copay |
| Non-preferred Brand | $150 copay |
| Specialty | $300 copay |
Lab Tests and Diagnostic Procedures
| X-rays | No charge |
| Imaging (CT/PET/MRI) | 20% coinsurance after deductible |
| Blood work | No charge |
Mental and Psychiatric Health Care
| Mental Health outpatient services | No charge |
| Psychiatric hospital stay | 20% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://planfinder.ghcscw.com/sbc/2412228.pdf |
| Drug and medication plan formulary | https://ghcscw.com/members/understanding-your-pharmacy-benefits/ |
| Search doctor list | https://providersearch.ghcscw.com/public/#/ |
