Silver Elite CSR 250 – EPO
73% cost sharing reduction [Popular Plan]
Network type: EPO
Coverage tier: Silver
Primary care visit: $30 copay
Specialist visit: $50 copay
Urgent care visit: $50 copay
Description
This plan has 73% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | EPO |
| Deductible | $3,850 per person $3,850 per person |
| Out-of-pocket max | $6,800 per person $13,600 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $30 copay |
| Specialist visit | $50 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $500 copay after deductible |
| Ambulance | $500 copay after deductible |
| Hospital stay (facility) | $450 copay per Day after deductible |
| Hospital stay (physician) | $75 copay after deductible |
| Outpatient procedure (facility) | $200 copay after deductible |
| Outpatient procedure (physician) | $75 copay after deductible |
| Physical rehabilitation | $75 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $450 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $3 copay |
| Brand | $75 copay |
| Non-preferred Brand | 50% coinsurance after deductible |
| Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $50 copay after deductible |
| Imaging (CT/PET/MRI) | $125 copay after deductible |
| Blood work | $10 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $50 copay |
| Psychiatric hospital stay | $450 copay per Day after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d3ul0st9g52g6o.cloudfront.net/2024/FL/sbc/2024_40572FL007001604.pdf |
| Drug and medication plan formulary | https://www.hioscar.com/search-documents/drug-formularies/ |
| Search doctor list | https://www.hioscar.com/search/?networkId=019&year=2024 |
