Active Choice Silver PPO

Health Insurance Plan Details (2024 Plan)

SBC doc

doctor lookup

HMO

Silver

Deductible (per individual)	/yr
Deductible (per family)	/yr
Max Out-of-Pocket (per individual)	$7,700 /yr
Max Out-of-Pocket (per family)	$15,400 /yr
Drug Deductible (per individual)
Drug Deductible (per family)
Drug Max Out-of-Pocket (per individual)
Drug Max Out-of-Pocket (per family)
Plan Type	HMO
Includes Child Dental?	Yes
Includes Adult Dental?	No

Medical Services
Preventive Care	No Charge
Primary Care Visit	$50 Copay with deductible
Specialist Visit	$50 Copay after deductible
Emergency Room	$200 Copay after deductible
Inpatient Facility	20.00% Coinsurance after deductible
Inpatient Physician	$0 Copay

Drug Costs
Generic Drugs	$15 Copay
Preferred Brand Drugs	$50 Copay after deductible
Non-preferred Brand Drugs	$70 Copay after deductible
Specialty Drugs	20.00% Coinsurance after deductible

Summary of Benefits and Coverage	SBC doc
Provider Directory	Doctor lookup
Drug Formulary List	n/a

* Figures shown are only for in-network medical costs

** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible

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