Standard Silver: Community Care Connector High Silver II – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $25 copay
Specialist visit: $60 copay
Urgent care visit: $60 copay
Description
Health Care Plan Details
Network type | HMO |
Deductible | $2,000 per person $2,000 per person |
Out-of-pocket max | $9,450 per person $18,900 per family |
Metal tier | Silver |
Visit Copay
Primary care visit | $25 copay |
Specialist visit | $60 copay |
Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
Urgent care | $60 copay |
Emergency room | $350 copay after deductible |
Ambulance | No charge after deductible |
Hospital stay (facility) | $1,000 copay after deductible |
Hospital stay (physician) | No charge after deductible |
Outpatient procedure (facility) | $500 copay after deductible |
Outpatient procedure (physician) | No charge after deductible |
Physical rehabilitation | $60 copay |
Maternitowny and Pregnancy
Labor, delivery, hospital stay | $1,000 copay after deductible |
Pharmacy, Drugs, and Medication
Generic | $30 copay |
Brand | $55 copay |
Non-preferred Brand | $75 copay after deductible |
Specialty | $75 copay after deductible |
Lab Tests and Diagnostic Procedures
X-rays | $50 copay after deductible |
Imaging (CT/PET/MRI) | $350 copay after deductible |
Blood work | $25 copay after deductible |
Mental and Psychiatric Health Care
Mental Health outpatient services | $25 copay |
Psychiatric hospital stay | $1,000 copay after deductible |