Silver Elite Saver Plus – 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: $15 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 | $1,200 per person $2,400 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 | $15 copay |
| Emergency room | 20% coinsurance |
| Ambulance | 20% coinsurance |
| Hospital stay (facility) | 20% coinsurance |
| Hospital stay (physician) | 20% coinsurance |
| Outpatient procedure (facility) | 20% coinsurance |
| Outpatient procedure (physician) | 20% coinsurance |
| Physical rehabilitation | $10 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 20% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | No charge |
| Brand | $30 copay after deductible |
| Non-preferred Brand | 50% after deductible |
| Specialty | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $10 copay |
| Imaging (CT/PET/MRI) | 20% coinsurance |
| Blood work | No charge |
Mental and Psychiatric Health Care
| Mental Health outpatient services | No charge |
| Psychiatric hospital stay | 20% coinsurance |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/R1WYQF1Vo6F3sxafXsucsDmu.pdf |
