Value Benchmark Platinum Standardized Plan

Health Insurance Plan Details (2024 Plan)

Monthly Premium

HMO
$ubsidy
Platinum
Deductible
$0 /yr
Max Out-of-Pocket
$3,200 /yr

Details

Deductible (per individual) $0 /yr
Deductible (per family) $0 /yr
Max Out-of-Pocket (per individual) $3,200 /yr
Max Out-of-Pocket (per family) $6,400 /yr
Drug Deductible (per individual) Included in Medical
Drug Deductible (per family) Included in Medical
Drug Max Out-of-Pocket (per individual) Included in Medical
Drug Max Out-of-Pocket (per family) Included in Medical
Plan Type HMO
Includes Child Dental? No
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit $10 Copay
Specialist Visit $20 Copay
Emergency Room $100 Copay
Inpatient Facility $350 Copay per Stay
Inpatient Physician 20% Coinsurance
Drug Costs
Generic Drugs $5 Copay
Preferred Brand Drugs $10 Copay
Non-preferred Brand Drugs $50 Copay
Specialty Drugs $150 Copay

Plan Documents

Summary of Benefits and Coverage SBC doc
Provider Directory Doctor lookup
Drug Formulary List drug list

* 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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