Gold Valley Advantage EPO 2150/10/20

Apply Off Pennie

Apply On Pennie

Plan overview

Plan availability
County of residence	Available in Lehigh and Northampton counties
Exchange	On and off Pennie

Covered services

Plan details	You pay
Deductible (individual / family)	$2,150 / $4,300
Out-of-pocket max (individual / family)	$8,550 / $17,100
Coinsurance	10%

Doctor visits	You pay
Primary care office visit	$20 copay
Specialist office visit	$45 copay

Emergencies	You pay
Emergency room	$300 copay after deductible
Urgent care	$75 copay

Tests and lab work	You pay
Diagnostic lab services	Paid in full after deductible
Outpatient diagnostic test (X-ray)	10% coinsurance after deductible
Outpatient high tech imaging	25% coinsurance after deductible

Hospital services	You pay
Outpatient surgery service	10% coinsurance after deductible
Inpatient hospital admission	10% coinsurance after deductible

Prescriptions	You pay
Retail Rx	Preferred generic¹: $10 Nonpreferred generic¹: 25% ($250 max) Preferred brand: $25 Nonpreferred brand: $75
Home delivery Rx	Preferred generic¹: $20 Nonpreferred generic¹: 25% ($500 max) Preferred brand: $50 Nonpreferred brand: $150

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

¹ Deductible waived for generic drugs

Sections

Plan availability

Tests and lab work

Hospital services

Plan documents

Highlight sheet

Summary of benefits and coverage

Benefits contract

Need more information?

Understanding health insurance

Complementary Content

${loading}