Silver Simple Diabetes – HMO

Network type: HMO
Coverage tier: Silver
Primary care visit: No charge
Specialist visit: $40 copay
Urgent care visit: $75 copay

Description

Health Care Plan Details

Network type HMO
Deductible $6,500 per person $6,500 per person
Out-of-pocket max $8,550 per person $17,100 per family
Metal tier Silver

Visit Copay

Primary care visit No charge
Specialist visit $40 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $75 copay
Emergency room 50% coinsurance after deductible
Ambulance 50% coinsurance after deductible
Hospital stay (facility) 50% coinsurance after deductible
Hospital stay (physician) 50% coinsurance after deductible
Outpatient procedure (facility) 50% coinsurance after deductible
Outpatient procedure (physician) 50% coinsurance after deductible
Physical rehabilitation 50% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay 50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic No charge
Brand $75 copay after deductible
Non-preferred Brand 50% coinsurance after deductible
Specialty 50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays 50% coinsurance after deductible
Imaging (CT/PET/MRI) 50% coinsurance after deductible
Blood work $10 copay

Mental and Psychiatric Health Care

Mental Health outpatient services No charge
Psychiatric hospital stay 50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://d3ul0st9g52g6o.cloudfront.net/2024/GA/sbc/2024_58081GA001004501.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