Silver 87 Ambetter PPO – PPO
87% cost sharing reduction [Popular Plan]
Network type: PPO
Coverage tier: Silver
Primary care visit: $15 copay
Specialist visit: $25 copay
Urgent care visit: $15 copay
Description
This plan has 87% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | PPO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $3,000 per person $6,000 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $15 copay |
| Specialist visit | $25 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $15 copay |
| Emergency room | $150 copay |
| Ambulance | $75 copay |
| Hospital stay (facility) | 20% coinsurance |
| Hospital stay (physician) | 20% coinsurance |
| Outpatient procedure (facility) | 20% coinsurance |
| Outpatient procedure (physician) | 20% coinsurance |
| Physical rehabilitation | $15 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 20% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | $5 copay |
| Brand | $25 copay |
| Non-preferred Brand | $45 copay |
| Specialty | 15%, up to $150 copay, 15%, up to $150 coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | $40 copay |
| Imaging (CT/PET/MRI) | $100 copay |
| Blood work | $20 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $15 copay |
| Psychiatric hospital stay | 20% coinsurance |
