SummaCare Silver 5000 1000 Rx with 3 Free PCP Visits – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$5,000 per person $5,000 per person
Out-of-pocket max	$8,900 per person $17,800 per family
Metal tier	Silver

Visit Copay

Primary care visit	$30 copay
Specialist visit	40% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	40% coinsurance after deductible
Emergency room	40% coinsurance after deductible
Ambulance	40% coinsurance after deductible
Hospital stay (facility)	40% coinsurance after deductible
Hospital stay (physician)	40% coinsurance after deductible
Outpatient procedure (facility)	40% coinsurance after deductible
Outpatient procedure (physician)	40% coinsurance after deductible
Physical rehabilitation	40% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	40% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$10 copay
Brand	40% coinsurance after deductible
Non-preferred Brand	50% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	40% coinsurance after deductible
Imaging (CT/PET/MRI)	40% coinsurance after deductible
Blood work	40% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$30 copay
Psychiatric hospital stay	40% 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-Silver-5000-1000-Rx-EHB-Only.pdf
Drug and medication plan formulary	https://client.formularynavigator.com/Search.aspx?siteCode=3823697592
Search doctor list	https://www.summacare.com/scconnect