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)

$6000 / $12,000

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 copay 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