SELECT GOLD I402 MAINTENANCE VALUE TIER RX

Health Insurance Plan Details (2024 Plan)

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
Medical Services
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
Drug Costs
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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