Silver QHDHP PPO 2900/10/40

Health Insurance Plan Details (2025 Plan)

SBC doc

doctor lookup

PPO

HSA

Silver

Deductible (per individual)	$2,900 /yr
Deductible (per family)	$5,800 /yr
Max Out-of-Pocket (per individual)	$7,450 /yr
Max Out-of-Pocket (per family)	$14,900 /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	PPO
Includes Child Dental?	Yes
Includes Adult Dental?	No

Medical Services
Preventive Care	No Charge
Primary Care Visit	$40 Copay after deductible
Specialist Visit	$85 Copay after deductible
Emergency Room	$400 Copay after deductible
Inpatient Facility	10.00% Coinsurance after deductible
Inpatient Physician	10.00% Coinsurance after deductible

Drug Costs
Generic Drugs	$10 Copay after deductible
Preferred Brand Drugs	$25 Copay after deductible
Non-preferred Brand Drugs	$75 Copay after deductible
Specialty Drugs	50.00% Coinsurance after deductible

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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