Value Gold $1,000 – PPO
Network type: PPO
Coverage tier: Gold
Primary care visit: $10 copay
Specialist visit: $30 copay
Urgent care visit: $40 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $1,000 per person $1,000 per person |
| Out-of-pocket max | $6,750 per person $13,500 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $10 copay |
| Specialist visit | $30 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $40 copay |
| Emergency room | $350 copay after deductible |
| Ambulance | $300 copay |
| Hospital stay (facility) | $450 copay after deductible |
| Hospital stay (physician) | $30 copay |
| Outpatient procedure (facility) | $250 copay |
| Outpatient procedure (physician) | $125 copay |
| Physical rehabilitation | $10 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $450 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 per script copay |
| Brand | $30 per script copay |
| Non-preferred Brand | $60 per script after deductible copay |
| Specialty | $75 per script after deductible copay |
Lab Tests and Diagnostic Procedures
| X-rays | $50 copay |
| Imaging (CT/PET/MRI) | $400 copay after deductible |
| Blood work | $25 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $10 copay |
| Psychiatric hospital stay | $450 copay after deductible |
