Smiling Father and Daughter by Tree

Plan overview

Plan availability

County of residence

Available in Lancaster county

Exchange

On and off Pennie

Covered services


Plan details

You pay

Deductible (individual/family)

Choice 1: $4,000 / $8,000

Choice 2: $8,550 / $17,100

Out-of-pocket max (individual/family)

$8,550 / $17,100

Coinsurance

Choice 1: 20%

Choice 2: None


Doctor visits

You pay

Primary care office visit

Choice 1: $35 copay

Choice 2: $60 copay

Specialist office visit

Choice 1: $65 copay

Choice 2: $85 copay


Emergencies

You pay

Emergency room

$400 copay after Choice 1 deductible

Urgent care

$100 copay


Tests and lab work

You pay

Diagnostic lab services

Choice 1: 20% after deductible

Choice 2: Paid in full after deductible

Outpatient diagnostic test (X-ray)

Choice 1: 20% after deductible

Choice 2: Paid in full after deductible

Outpatient high tech imaging

Choice 1: 20% after deductible

Choice 2: Paid in full after deductible


Hospital services

You pay

Outpatient surgery service

Choice 1: 20% after deductible

Choice 2: Paid in full after deductible

Inpatient hospital admission

Choice 1: 20% after deductible

Choice 2: Paid in full 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