myBlue Silver 2204 ($0 Virtual Visits / Rewards $$$)

Health Insurance Plan Details (2024 Plan)

Monthly Premium

HMO
$ubsidy
Silver
Deductible
$4,750 /yr
Max Out-of-Pocket
$7,800 /yr

Details

Deductible (per individual) $4,750 /yr
Deductible (per family) $9,500 /yr
Max Out-of-Pocket (per individual) $7,800 /yr
Max Out-of-Pocket (per family) $15,600 /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 No Charge
Specialist Visit $20 Copay
Emergency Room $650 Copay after deductible
Inpatient Facility 40% Coinsurance after deductible
Inpatient Physician No Charge
Drug Costs
Generic Drugs $25 Copay
Preferred Brand Drugs $55 Copay after deductible
Non-preferred Brand Drugs 50% Coinsurance after deductible
Specialty Drugs 50% Coinsurance 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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