Standard Platinum: Community Care Connector Platinum – HMO

Network type: HMO
Coverage tier: Platinum
Primary care visit: $20 copay
Specialist visit: $40 copay
Urgent care visit: $40 copay

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Description

Health Care Plan Details

Network type HMO
Deductible $0 per person $0 per person
Out-of-pocket max $3,000 per person $6,000 per family
Metal tier Platinum

Visit Copay

Primary care visit $20 copay
Specialist visit $40 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $40 copay
Emergency room $150 copay
Ambulance No charge
Hospital stay (facility) $500 copay
Hospital stay (physician) No charge
Outpatient procedure (facility) $250 copay
Outpatient procedure (physician) No charge
Physical rehabilitation $40 copay

Maternitowny and Pregnancy

Labor, delivery, hospital stay $500 copay

Pharmacy, Drugs, and Medication

Generic $10 copay
Brand $25 copay
Non-preferred Brand $50 copay
Specialty $50 copay

Lab Tests and Diagnostic Procedures

X-rays No charge
Imaging (CT/PET/MRI) $150 copay
Blood work No charge

Mental and Psychiatric Health Care

Mental Health outpatient services $20 copay
Psychiatric hospital stay $500 copay

Health Plan Provider Information