Silver Simple PCP Saver CSR 150, Silver, NS, INN, Circle, Wellness Rewards DP FP – EPO
94% cost sharing reduction [Popular Plan]
Network type: EPO
Coverage tier: Silver
Primary care visit: $5 copay
Specialist visit: $10 copay
Urgent care visit: $25 copay
Description
This plan has 94% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | EPO |
| Deductible | $90 per person $90 per person |
| Out-of-pocket max | $1,000 per person $2,000 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $5 copay |
| Specialist visit | $10 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $25 copay |
| 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 | $10 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 20% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $5 copay |
| Brand | $20 copay |
| Non-preferred Brand | 20% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $25 copay |
| Imaging (CT/PET/MRI) | $80 copay |
| Blood work | $10 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $5 copay |
| Psychiatric hospital stay | 20% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/xNKaRoyXGqHGRPA4tzbtKc5b.pdf |
