Silver 5000 w/ GYM – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $40 copay
Specialist visit: $90 copay
Urgent care visit: $40 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 | $40 copay |
| Specialist visit | $90 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $40 copay |
| Emergency room | $1,050 copay |
| Ambulance | 30% after deductible |
| Hospital stay (facility) | 30% after deductible |
| Hospital stay (physician) | 30% after deductible |
| Outpatient procedure (facility) | 30% after deductible |
| Outpatient procedure (physician) | 30% after deductible |
| Physical rehabilitation | $40 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 30% after deductible |
Pharmacy, Drugs, and Medication
| Generic | No charge |
| Brand | $125 copay |
| Non-preferred Brand | 30% after deductible |
| Specialty | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $125 per procedure copay |
| Imaging (CT/PET/MRI) | 30% after deductible |
| Blood work | $50 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | No charge |
| Psychiatric hospital stay | No charge |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/g1ppjbVghmpzAfcCGU358o4g.pdf |
| Drug and medication plan formulary | https://client.formularynavigator.com/Search.aspx?siteCode=0324498195 |
