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)

No deductible

Out-of-pocket max (individual / family)

$8,550 / $17,100

Coinsurance

None


Doctor visits

You pay

Primary care office visit

$25 copay

Specialist office visit

$50 copay


Emergencies

You pay

Emergency room

$200 copay

Urgent care

$50 copay


Tests and lab work

You pay

Diagnostic lab services

$25 copay for independent clinical labs / $50 copay for facility owned labs

Outpatient diagnostic test (X-ray)

$25 copay

Outpatient high tech imaging

$200 copay


Hospital services

You pay

Outpatient surgery service

$2,000 copay

Inpatient hospital admission

$4,000 copay per admission


Prescriptions

You pay

Retail Rx

Preferred generic: $4 
Nonpreferred generic: $15 
Preferred brand: $45 
Nonpreferred brand: $70

Home delivery Rx

Preferred generic: $8 
Nonpreferred generic: $30 
Preferred brand: $90 
Nonpreferred brand: $140


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