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SELECT GOLD I402 MAINTENANCE VALUE TIER RX
Health Insurance Plan Details (2024 Plan)
by Quartz
Monthly Premium
HMO
$ubsidy
Gold
- Deductible
- $500 /yr
- Max Out-of-Pocket
- $9,000 /yr
Details
| Deductible (per individual) | $500 /yr |
| Deductible (per family) | $1,000 /yr |
| Max Out-of-Pocket (per individual) | $9,000 /yr |
| Max Out-of-Pocket (per family) | $18,000 /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? | No |
| Includes Adult Dental? | No |
Out-of-Pocket Costs
| Preventive Care | No Charge |
| Primary Care Visit | $35 Copay |
| Specialist Visit | $70 Copay |
| Emergency Room | $500 Copay |
| Inpatient Facility | $2500 Copay per Day |
| Inpatient Physician | 0.00% Coinsurance after deductible |
| Generic Drugs | $10 Copay |
| Preferred Brand Drugs | $40 Copay |
| Non-preferred Brand Drugs | 50.00% Coinsurance |
| Specialty Drugs | 60.00% Coinsurance |
Plan Documents
| 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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