Active Choice Silver PPO

Health Insurance Plan Details (2024 Plan)

by Chinese Community Health Plan

Monthly Premium

HMO
$ubsidy
Silver
Deductible
N/A
Max Out-of-Pocket
$7,700 /yr

Details

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

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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