SELECT GOLD I402-01 MAINTENANCE VALUE TIER RX W/DENTAL – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $35 copay
Specialist visit: $70 copay
Urgent care visit: $70 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $500 per person $500 per person |
| Out-of-pocket max | $9,000 per person $18,000 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $35 copay |
| Specialist visit | $70 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $70 copay |
| Emergency room | $500 copay |
| Ambulance | No charge after deductible |
| Hospital stay (facility) | $2,500 per day copay |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | No charge after deductible |
| Outpatient procedure (physician) | No charge after deductible |
| Physical rehabilitation | $50 copay after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $2,500 per day copay |
Pharmacy, Drugs, and Medication
| Generic | $5 per script copay |
| Brand | $5 per script copay |
| Non-preferred Brand | 50% coinsurance |
| Specialty | 60% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | $70 per day copay |
| Imaging (CT/PET/MRI) | $150 copay after deductible |
| Blood work | $35 per day copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $35 copay |
| Psychiatric hospital stay | $2,500 per day copay |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/pHuS34JEdz7XqzhMXajeUAQX.pdf |
| Drug and medication plan formulary | https://quartzbenefits.com/members/pharmacy-program/covered-drugs/standard-formularies/ |
