Silver Select 7000 w/ GYM – Limited Service Area – HMO
73% cost sharing reduction [Popular Plan]
Network type: HMO
Coverage tier: Silver
Primary care visit: $40 copay
Specialist visit: $80 copay
Urgent care visit: $40 copay
Description
This plan has 73% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | HMO |
| Deductible | $3,350 per person $3,350 per person |
| Out-of-pocket max | $7,550 per person $15,100 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $40 copay |
| Specialist visit | $80 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $40 copay |
| Emergency room | $750 copay |
| Ambulance | 10% after deductible |
| Hospital stay (facility) | 10% after deductible |
| Hospital stay (physician) | 10% after deductible |
| Outpatient procedure (facility) | 10% after deductible |
| Outpatient procedure (physician) | 10% after deductible |
| Physical rehabilitation | $40 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 10% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $20 copay |
| Brand | $120 copay |
| Non-preferred Brand | 10% after deductible |
| Specialty | 10% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $110 copay |
| Imaging (CT/PET/MRI) | 10% after deductible |
| Blood work | $50 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | No charge |
| Psychiatric hospital stay | No charge |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/B3mJMHaPpgn9ttWUW2Lujxzz.pdf |
| Drug and medication plan formulary | https://client.formularynavigator.com/Search.aspx?siteCode=0324498195 |
