Silver Simple PCP Saver CSR 200, Silver, NS, INN, Circle Wellness Rewards DP FP Dep 29 – EPO
87% cost sharing reduction [Popular Plan]
Network type: EPO
Coverage tier: Silver
Primary care visit: $10 copay
Specialist visit: $25 copay
Urgent care visit: $50 copay
Description
This plan has 87% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | EPO |
| Deductible | $1,650 per person $1,650 per person |
| Out-of-pocket max | $2,600 per person $5,200 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $10 copay |
| Specialist visit | $25 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | 40% after deductible |
| Ambulance | 40% after deductible |
| Hospital stay (facility) | 40% after deductible |
| Hospital stay (physician) | 40% after deductible |
| Outpatient procedure (facility) | 40% after deductible |
| Outpatient procedure (physician) | 40% after deductible |
| Physical rehabilitation | $25 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 40% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $8 copay |
| Brand | $30 copay |
| Non-preferred Brand | 40% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $50 copay |
| Imaging (CT/PET/MRI) | $100 copay |
| Blood work | $25 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $10 copay |
| Psychiatric hospital stay | 40% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/33vxrUXakwHcKwa1wc7NHHWS.pdf |
