Standard Platinum: WellSense Clarity Platinum 0 Deductible – HMO
Network type: HMO
Coverage tier: Platinum
Primary care visit: $20 copay
Specialist visit: $40 copay
Urgent care visit: $40 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | Success
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| 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 |
