Silver Classic Standard CSR 150 | MercyOne – EPO
94% cost sharing reduction [Popular Plan]
Network type: EPO
Coverage tier: Silver
Primary care visit: No charge
Specialist visit: $10 copay
Urgent care visit: $5 copay
Description
This plan has 94% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | EPO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $1,800 per person $3,600 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | No charge |
| Specialist visit | $10 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $5 copay |
| Emergency room | 25% coinsurance |
| Ambulance | 25% coinsurance |
| Hospital stay (facility) | 25% coinsurance |
| Hospital stay (physician) | 25% coinsurance |
| Outpatient procedure (facility) | 25% coinsurance |
| Outpatient procedure (physician) | 25% coinsurance |
| Physical rehabilitation | No charge |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 25% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | No charge |
| Brand | $15 copay |
| Non-preferred Brand | $50 copay |
| Specialty | $150 copay |
Lab Tests and Diagnostic Procedures
| X-rays | 25% coinsurance |
| Imaging (CT/PET/MRI) | 25% coinsurance |
| Blood work | 25% coinsurance |
Mental and Psychiatric Health Care
| Mental Health outpatient services | No charge |
| Psychiatric hospital stay | 25% coinsurance |
Health Plan Provider Information
| Health Plan Benefits | https://d3ul0st9g52g6o.cloudfront.net/2024/IA/sbc/2024_45819IA001005206.pdf |
| Drug and medication plan formulary | https://www.hioscar.com/search-documents/drug-formularies/ |
| Search doctor list | https://www.hioscar.com/search/?networkId=041&year=2024 |
