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
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 |