Virtual Plus Silver – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $20 copay
Specialist visit: $50 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
Network type | HMO |
Deductible | $3,000 per person $3,000 per person |
Out-of-pocket max | $9,175 per person $18,350 per family |
Metal tier | Silver |
Visit Copay
Primary care visit | $20 copay |
Specialist visit | $50 copay |
Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
Urgent care | $50 copay |
Emergency room | 30% after deductible |
Ambulance | 30% after deductible |
Hospital stay (facility) | 30% after deductible |
Hospital stay (physician) | 30% after deductible |
Outpatient procedure (facility) | 30% after deductible |
Outpatient procedure (physician) | 30% after deductible |
Physical rehabilitation | $50 copay |
Maternitowny and Pregnancy
Labor, delivery, hospital stay | 30% after deductible |
Pharmacy, Drugs, and Medication
Generic | $25 per script copay |
Brand | 50% after deductible |
Non-preferred Brand | 50% after deductible |
Specialty | 50% after deductible |
Lab Tests and Diagnostic Procedures
X-rays | 30% after deductible |
Imaging (CT/PET/MRI) | 30% after deductible |
Blood work | 30% after deductible |
Mental and Psychiatric Health Care
Mental Health outpatient services | $20 copay |
Psychiatric hospital stay | 30% after deductible |
Health Plan Provider Information
Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/yu82usXGMERjkJg1P5YvZ796.pdf |
Drug and medication plan formulary | https://wa.kaiserpermanente.org/static/pdf/public/formulary/if-sg-2024.pdf?kp_shortcut_referrer=kp.org/wa/7formulary2024 |