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)

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.