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 |