Silver 70 Trio HMO – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $50 copay
Specialist visit: $90 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $5,400 per person $5,400 per person |
| Out-of-pocket max | $9,100 per person $18,200 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $50 copay |
| Specialist visit | $90 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $450 copay |
| Ambulance | $250 copay |
| Hospital stay (facility) | 30% after deductible |
| Hospital stay (physician) | 30% coinsurance |
| Outpatient procedure (facility) | 30% coinsurance |
| Outpatient procedure (physician) | 30% coinsurance |
| Physical rehabilitation | $50 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 30% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $19 copay |
| Brand | $60 copay after deductible |
| Non-preferred Brand | $90 copay after deductible |
| Specialty | 20% after deductible, up to $250 copay, 20% after deductible, up to $250 |
Lab Tests and Diagnostic Procedures
| X-rays | $95 copay |
| Imaging (CT/PET/MRI) | $325 copay |
| Blood work | $50 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $50 copay |
| Psychiatric hospital stay | 30% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/zeH66cNu1K6sZnoX1FMEuGUR.pdf |
