SummaCare Gold 2000 with 3 Free PCP Visits + Travel Assistance + Adult Vision Exam – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $15 copay
Specialist visit: $50 copay
Urgent care visit: $75 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $2,000 per person $2,000 per person |
| Out-of-pocket max | $8,000 per person $16,000 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $15 copay |
| Specialist visit | $50 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay |
| Emergency room | $500 copay after deductible |
| Ambulance | 20% coinsurance after deductible |
| Hospital stay (facility) | 20% coinsurance after deductible |
| Hospital stay (physician) | 20% coinsurance after deductible |
| Outpatient procedure (facility) | 20% coinsurance after deductible |
| Outpatient procedure (physician) | 20% coinsurance after deductible |
| Physical rehabilitation | $50 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 20% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $15 copay |
| Brand | $50 copay |
| Non-preferred Brand | 50% coinsurance after deductible |
| Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 20% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 20% coinsurance after deductible |
| Blood work | 20% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $15 copay |
| Psychiatric hospital stay | 20% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.summacare.com/-/media/Project/SummaCare/Website/Document-Library/SBCs/IFP/2024/2024-SBC-SummaCare-Gold-2000.pdf |
| Drug and medication plan formulary | https://client.formularynavigator.com/Search.aspx?siteCode=3823697592 |
| Search doctor list | https://www.summacare.com/scconnect |
