Silver 203 – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $15 copay
Specialist visit: 35% after deductible
Urgent care visit: $60 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | See brochure See brochure |
| Out-of-pocket max | N/A per person N/A per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $15 copay |
| Specialist visit | 35% after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $60 copay |
| Emergency room | 35% after deductible |
| Ambulance | 35% after deductible |
| Hospital stay (facility) | 35% after deductible |
| Hospital stay (physician) | 35% after deductible |
| Outpatient procedure (facility) | 35% after deductible |
| Outpatient procedure (physician) | 35% after deductible |
| Physical rehabilitation | 35% after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 35% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $3 copay |
| Brand | $75 copay |
| Non-preferred Brand | 50% after deductible |
| Specialty | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 35% after deductible |
| Imaging (CT/PET/MRI) | 35% after deductible |
| Blood work | $35 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 25% coinsurance |
| Psychiatric hospital stay | 35% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/Gk5sbPFjoZPmLarBHjVCVJ1f.pdf |
| Drug and medication plan formulary | https://ambetter.pahealthwellness.com/resources/pharmacy-resources.html |
| Search doctor list | https://ambetter.pahealthwellness.com/findadoc |
