SELECT SILVER I308-06 VALUE TIER RX W/DENTAL W/FIXED COPAY – HMO
94% cost sharing reduction [Popular Plan]
Network type: HMO
Coverage tier: Silver
Primary care visit: No charge
Specialist visit: $10 copay
Urgent care visit: $10 copay
Description
This plan has 94% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | HMO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $1,250 per person $2,500 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | No charge |
| Specialist visit | $10 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $10 copay |
| Emergency room | $50 copay |
| Ambulance | 50% coinsurance |
| Hospital stay (facility) | $125 per day copay |
| Hospital stay (physician) | 50% coinsurance |
| Outpatient procedure (facility) | $100 copay |
| Outpatient procedure (physician) | 50% coinsurance |
| Physical rehabilitation | $10 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $125 per day copay |
Pharmacy, Drugs, and Medication
| Generic | No charge |
| Brand | No charge |
| Non-preferred Brand | $100 per script copay |
| Specialty | $200 per script copay |
Lab Tests and Diagnostic Procedures
| X-rays | $10 per day copay |
| Imaging (CT/PET/MRI) | $100 per day copay |
| Blood work | $10 per day copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | No charge |
| Psychiatric hospital stay | $125 per day copay |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/SJHrM2NvqUGix2cwChHXGEyH.pdf |
| Drug and medication plan formulary | https://quartzbenefits.com/members/pharmacy-program/covered-drugs/standard-formularies/ |
