Connected Silver (QualChoice)

Health Insurance Plan Details (2024 Plan)

by QCA Health Plan, Inc.

Monthly Premium

POS
$ubsidy
Silver
Deductible
$7,350 /yr
Max Out-of-Pocket
$9,450 /yr

Details

Deductible (per individual) $7,350 /yr
Deductible (per family) $14,700 /yr
Max Out-of-Pocket (per individual) $9,450 /yr
Max Out-of-Pocket (per family) $18,900 /yr
Drug Deductible (per individual) $1,000
Drug Deductible (per family) $2,000
Drug Max Out-of-Pocket (per individual) Included in Medical
Drug Max Out-of-Pocket (per family) Included in Medical
Plan Type POS
Includes Child Dental? No
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit $55 Copay
Specialist Visit $75 Copay
Emergency Room $250 Copay after deductible
Inpatient Facility $1,000 Copay per Day after deductible
Inpatient Physician No Charge after Deductible
Drug Costs
Generic Drugs $15 Copay
Preferred Brand Drugs $50 Copay
Non-preferred Brand Drugs $100 Copay after deductible
Specialty Drugs $250 Copay after deductible

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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