Silver 1 250 with Adult Vision Services – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $30 copay
Specialist visit: $60 copay
Urgent care visit: $45 copay
Description
Health Care Plan Details
Network type | HMO |
Deductible | $5,000 per person $5,000 per person |
Out-of-pocket max | $7,850 per person $15,700 per family |
Metal tier | Silver |
Visit Copay
Primary care visit | $30 copay |
Specialist visit | $60 copay |
Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
Urgent care | $45 copay |
Emergency room | 35% coinsurance after deductible |
Ambulance | 35% coinsurance after deductible |
Hospital stay (facility) | 35% coinsurance after deductible |
Hospital stay (physician) | 35% coinsurance after deductible |
Outpatient procedure (facility) | 35% after deductible |
Outpatient procedure (physician) | 35% coinsurance after deductible |
Physical rehabilitation | $30 copay |
Maternitowny and Pregnancy
Labor, delivery, hospital stay | 35% coinsurance after deductible |
Pharmacy, Drugs, and Medication
Generic | $29 copay |
Brand | $65 copay after deductible |
Non-preferred Brand | 35% coinsurance after deductible |
Specialty | 35% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
X-rays | $95 copay |
Imaging (CT/PET/MRI) | 35% coinsurance after deductible |
Blood work | $60 copay |
Mental and Psychiatric Health Care
Mental Health outpatient services | $30 copay |
Psychiatric hospital stay | 35% coinsurance after deductible |
Health Plan Provider Information
Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/K2SYUd6oZiNfiAFZDwNKDyeP.pdf |