Value Silver – HMO

Network type: HMO
Coverage tier: Silver
Primary care visit: $35 copay
Specialist visit: $90 copay
Urgent care visit: $75 copay

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Description

Health Care Plan Details

Network type HMO
Deductible $4,500 per person $4,500 per person
Out-of-pocket max $7,600 per person $15,200 per family
Metal tier Silver

Visit Copay

Primary care visit $35 copay
Specialist visit $90 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $75 copay
Emergency room $500 copay after deductible
Ambulance $350 copay
Hospital stay (facility) $550 copay after deductible
Hospital stay (physician) $40 copay
Outpatient procedure (facility) $150 copay after deductible
Outpatient procedure (physician) $150 copay after deductible
Physical rehabilitation $35 copay

Maternitowny and Pregnancy

Labor, delivery, hospital stay $550 copay after deductible

Pharmacy, Drugs, and Medication

Generic $25 per script copay
Brand $75 per script after deductible copay
Non-preferred Brand $80 per script after deductible copay
Specialty $100 per script after deductible copay

Lab Tests and Diagnostic Procedures

X-rays $150 copay
Imaging (CT/PET/MRI) $600 copay after deductible
Blood work $80 copay

Mental and Psychiatric Health Care

Mental Health outpatient services $35 copay
Psychiatric hospital stay $550 copay after deductible

Health Plan Provider Information