Silver 3 250 – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $55 copay
Specialist visit: $100 copay
Urgent care visit: $75 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $55 copay |
| Specialist visit | $100 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay |
| Emergency room | 50% coinsurance |
| Ambulance | 50% coinsurance |
| Hospital stay (facility) | 50% coinsurance |
| Hospital stay (physician) | 50% coinsurance |
| Outpatient procedure (facility) | 50% coinsurance |
| Outpatient procedure (physician) | 50% coinsurance |
| Physical rehabilitation | 50% coinsurance |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 50% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | $30 copay |
| Brand | $150 copay |
| Non-preferred Brand | 50% coinsurance |
| Specialty | 50% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | $125 copay |
| Imaging (CT/PET/MRI) | 50% coinsurance |
| Blood work | $60 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $55 copay |
| Psychiatric hospital stay | 50% coinsurance |
Health Plan Provider Information
| Health Plan Benefits | https://www.molinamarketplace.com/members/tx/en-US/PDF/Marketplace/2024/TX24SBCE_S3_1.pdf |
| Drug and medication plan formulary | https://www.molinamarketplace.com/members/tx/en-US/PDF/Marketplace/2024/TXFormulary2024.pdf |
| Search doctor list | https://molina.sapphirethreesixtyfive.com//?ci=tx-marketplace |
