Smiling Father and Daughter by Tree

Plan overview

Plan availability

County of residence

Available in all counties except Lancaster

Exchange

Off Pennie

Covered services


Plan details

You pay

Deductible (individual / family)

$5,950 / $11,900

Out-of-pocket max (individual / family)

$8,550 / $17,100

Coinsurance

20%


Doctor visits

You pay

Primary care office visit

$40 copay

Specialist office visit

$85 copay


Emergencies

You pay

Emergency room

$400 after deductible

Urgent care

$100 copay


Tests and lab work

You pay

Diagnostic lab services

$25 copay (deductible waived) for independent clinical labs / $75 copay after deductible for facility owned labs

Outpatient diagnostic test (X-ray)

20% coinsurance after deductible

Outpatient high tech imaging

35% coinsurance after deductible


Hospital services

You pay

Outpatient surgery service

20% coinsurance after deductible

Inpatient hospital admission

20% coinsurance after deductible


Prescriptions

You pay

Retail Rx

Preferred generic1: $10 
Nonpreferred generic1: 25% ($250 max) 
Preferred brand: $50 
Nonpreferred brand: $100

Home delivery Rx

Preferred generic1: $20 
Nonpreferred generic1: 25% ($500 max) 
Preferred brand: $100 
Nonpreferred brand: $200


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

1 Deductible waived for generic drugs