Silver Simple CSR 200 – HMO
87% cost sharing reduction [Popular Plan]
Network type: HMO
Coverage tier: Silver
Primary care visit: $15 copay
Specialist visit: $40 copay
Urgent care visit: $45 copay
Description
This plan has 87% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | HMO |
| Deductible | $725 per person $725 per person |
| Out-of-pocket max | $2,600 per person $5,200 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $15 copay |
| Specialist visit | $40 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $45 copay |
| Emergency room | 25% coinsurance after deductible |
| Ambulance | 25% coinsurance after deductible |
| Hospital stay (facility) | 25% coinsurance after deductible |
| Hospital stay (physician) | 25% coinsurance after deductible |
| Outpatient procedure (facility) | 25% coinsurance after deductible |
| Outpatient procedure (physician) | 25% coinsurance after deductible |
| Physical rehabilitation | $40 copay after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 25% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $3 copay |
| Brand | $60 copay |
| Non-preferred Brand | 25% coinsurance after deductible |
| Specialty | 25% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $30 copay after deductible |
| Imaging (CT/PET/MRI) | 25% coinsurance after deductible |
| Blood work | $10 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $40 copay |
| Psychiatric hospital stay | 25% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d3ul0st9g52g6o.cloudfront.net/2024/GA/sbc/2024_58081GA001001505.pdf |
| Drug and medication plan formulary | https://www.hioscar.com/search-documents/drug-formularies/ |
| Search doctor list | https://www.hioscar.com/search/?networkId=025&year=2024 |
