Silver Performance PPO 4500/20/35 + Silver + PPO – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: $35 copay
Specialist visit: $65 copay
Urgent care visit: $100 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $4,500 per person $4,500 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $35 copay |
| Specialist visit | $65 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $100 copay |
| Emergency room | $400 copay after deductible |
| Ambulance | 20% after deductible |
| Hospital stay (facility) | 20% after deductible |
| Hospital stay (physician) | 20% after deductible |
| Outpatient procedure (facility) | 20% after deductible |
| Outpatient procedure (physician) | 20% after deductible |
| Physical rehabilitation | $65 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 20% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 per script copay |
| Brand | $50 per script after deductible copay |
| Non-preferred Brand | $100 per script after deductible copay |
| Specialty | 50% after deductible, up to $800 per script copay, 50% after deductible, up to $800 per script |
Lab Tests and Diagnostic Procedures
| X-rays | 20% after deductible |
| Imaging (CT/PET/MRI) | 20% after deductible |
| Blood work | 20% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $35 copay |
| Psychiatric hospital stay | 20% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/8oRrGh64wRvQmzdXN8qApYxT.pdf |
| Drug and medication plan formulary | https://www.healthcare.gov/sbc-glossary/#prescription-drug-coverage |
