Smiling Father and Daughter by Tree

Plan overview

Plan availability

County of residence

Available in all counties except Lancaster

Exchange

On and off Pennie

Covered services


Plan details

You pay

Deductible (individual / family)

$8,000 / $16,000

Out-of-pocket max (individual / family)

$8,550 / $17,100

Coinsurance

None


Doctor visits

You pay

Primary care office visit

$50 copay

Specialist office visit

$85 copay


Emergencies

You pay

Emergency room

Paid in full after deductible

Urgent care

Paid in full after deductible


Tests and lab work

You pay

Diagnostic lab services

$25 copay (deductible waived) for independent clinical labs / Paid in full after deductible for facility owned labs

Outpatient diagnostic test (X-ray)

Paid in full after deductible

Outpatient high tech imaging

Paid in full after deductible


Hospital services

You pay

Outpatient surgery service

Paid in full after deductible

Inpatient hospital admission

Paid in full after deductible


Prescriptions

You pay

Retail Rx

Paid in full after deductible

Home delivery Rx

Paid in full after deductible


Cost Share amounts listed in the chart are for service performed at in-network providers.