Silver Qualified HDHP/HSA plan w/ GYM – HMO

Network type: HMO
Coverage tier: Silver
Primary care visit: 20% after deductible
Specialist visit: 20% after deductible
Urgent care visit: 20% after deductible

SKU: 57173NM0310001 Category:

Description

Health Care Plan Details

Network type HMO
Deductible See brochure See brochure
Out-of-pocket max N/A per person N/A per family
Metal tier Silver

Visit Copay

Primary care visit 20% after deductible
Specialist visit 20% after deductible
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care 20% after deductible
Emergency room 20% 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 20% after deductible

Maternitowny and Pregnancy

Labor, delivery, hospital stay 20% after deductible

Pharmacy, Drugs, and Medication

Generic No charge after deductible
Brand 20% after deductible
Non-preferred Brand 20% after deductible
Specialty 20% after deductible

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 No charge after deductible
Psychiatric hospital stay No charge after deductible

Health Plan Provider Information

Health Plan Benefits https://d2ed110nmrd591.cloudfront.net/blobs/ctwG1HGdUj5bEqoodZop7YXF.pdf
Drug and medication plan formulary https://client.formularynavigator.com/Search.aspx?siteCode=0324498195