Silver 12 100 with first 4 free PCP or MH visits – HMO

Description

This plan has 94% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	HMO
Deductible	$100 per person $100 per person
Out-of-pocket max	$3,150 per person $6,300 per family
Metal tier	Silver

Visit Copay

Primary care visit	$2 copay
Specialist visit	$4 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$3 copay
Emergency room	10% coinsurance after deductible
Ambulance	10% coinsurance after deductible
Hospital stay (facility)	10% coinsurance after deductible
Hospital stay (physician)	10% coinsurance after deductible
Outpatient procedure (facility)	10% coinsurance after deductible
Outpatient procedure (physician)	10% coinsurance after deductible
Physical rehabilitation	10% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	10% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$2 copay
Brand	$20 copay
Non-preferred Brand	10% coinsurance after deductible
Specialty	10% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	10% coinsurance after deductible
Imaging (CT/PET/MRI)	10% coinsurance after deductible
Blood work	10% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$2 copay
Psychiatric hospital stay	10% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://www.molinamarketplace.com/members/il/en-US/PDF/Marketplace/2024/IL24SBCE_S12_6.pdf
Drug and medication plan formulary	https://www.molinamarketplace.com/members/il/en-US/PDF/Marketplace/2024/ILFormulary2024.pdf
Search doctor list	https://molina.sapphirethreesixtyfive.com//?ci=il-marketplace