Value Silver – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: $35 copay
Specialist visit: $90 copay
Urgent care visit: $75 copay
Description
Health Care Plan Details
| Network type | PPO |
| 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 after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $550 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $25 per script after deductible 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 |
