Benefits | Essential Plan 1 Costs & Co-pays |
---|---|
Individual Deductible | $0 (Med/Rx combined) |
Individual Maximum Out-of-Pocket | $2,000 (Med/Rx combined) |
Inpatient Hospital Care | $150 |
Emergency Care | $75 |
Urgent Care | $25 |
Outpatient Hospital Services | $50 |
X-rays and Labs | PCP: $15 SPC: $25 OP Facility: $50 |
Advanced Imaging | $25 |
PCP Office Visits | $15 |
Specialist Office Visits | $25 |
Adult Dental NC/Covered | Not Covered/$15 if covered |
Adult Vision NC/Covered | Not Covered/$15 if covered |
Non-Prescription Drugs | Not Covered |
Non-Emergency Transportation | Not Covered |
Generic drugs | $6 |
Preferred Brand Drugs | $15 |
Non-Preferred Brand and Specialty | $30 |
Solomon Agency Corp.