Enhanced Silver 73

The amounts (co-pays) listed in the chart below are what you are responsible to pay when using in-network Doctors and Hospitals.
Key benefits Silver 73
Benefits in Orange are Subject to Deductibles
Copays in Black are Not Subject to any Deductible and Count Toward the Anual Out-Of-Pocket Maximum
Individual Deductible $2,200 medical
$130 pharmacy
Family Deductible $4,400 medical
$260 pharmacy
Preventative Care no cost1
Primary Care Visit Copay $30
Urgent Care Visit Copay $30
Specialty Care Visit Copay $75
Mental Health & Substance Abuse Outpatient Office Visits $30
Lab Testing Copay $35
X-Ray Copay $75
Imaging Copay $300
Outpatient services 20%
Emergency Room Copay $350
Emergency Room Transportation Copay $250
High cost and inpatient services (e.g. Hospital stay) 20%
Inpatient Hospital Physician services 20%
Tier 1 - Most Generic Drugs $15
Tier 2 - Preferred Brand Drugs $50
Tier 3 - Non-Preferred Brand Drugs $75
Tier 4 - Specialty Drugs 20% up to $250 maximum per prescription
Maximum Out-Of-Pocket For One $6,300
Maximum Out-Of-Pocket For Family $12,600
1 in-network only
2 Copay is limited to the first three visits in total. That includes any combination of Primary Care, Specialist or Urgent Care visits. After three visits, future visits will be at full cost until the out-of-pocket maximum is met.
3 See the plan's Summary of Benefits to determine if $ or % is due.
Key benefits Silver 73