Capital - Gold PPO 2000/10/20

Pennsylvania, 2019

  • Plan Type

    PPO

  • Metal Tier

    Gold

  • Out of Pocket Maximum

    $7,350

  • Deductible

    $2,000

Enroll Now
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Call (855) 866-5590 to speak with a licensed agent about a new health plan.

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Cost Sharing Benefits (In Network)

Policyholders are generally responsible for 100% of costs until the deductible amount is met. After the deductible has been met the policyholder is responsible for the coinsurance / copay until the out of pocket maximum is reached at which point the insurance company assumes 100% of all costs.

Deductible (Individual) $2,000
Deductible (Family) $4,000
Coinsurance Not applicable
Out of Pocket Maximum (Individual) $7,350
Out of Pocket Maximum (Family) $14,700

Doctor Visits

Primary Care Visit Data Not Available
Specialist Visit Data Not Available
Inpatient Facility 10% Coinsurance after deductible
Inpatient Physician 10% Coinsurance after deductible
Emergency Room Services $300 Copay after deductible

Tests and Imaging

Imaging (CT/PET Scans, MRIs) 25% Coinsurance after deductible
Laboratory Outpatient and Professional Services Data Not Available
X-Ray and Diagnostic Imaging 10% Coinsurance after deductible

Health Management Programs

Asthma Available
Depression Available
Diabetes Available
Heart Disease Available
High Blood Pressure / High Cholesterol Not available
Lower Back Pain Not available
Pain Management Not available
Pregnancy Available
Weight Loss Not available

Other

Mental / Behavioral Health Inpatient 10% Coinsurance after deductible
Mental / Behavioral Health Outpatient Data Not Available
Rehabilitative Speech Therapy Data Not Available
Rehabilitative Occupational & Physical Therapy Data Not Available
Outpatient Facility Data Not Available
Outpatient Surgery Data Not Available

Prescription Drugs

Generic Rx Data Not Available
Preferred Brand Rx $25 Copay after deductible
Non Preferred Brand Rx $75 Copay after deductible
Specialty Drugs 40% Coinsurance after deductible

Other Plans in Pennsylvania

Plan Silver PPO 5000/10/30 Deductible $5,000 Coinsurance Not applicable Out of Pocket $7,350
Plan Bronze PPO 7350/0/60 Deductible $7,350 Coinsurance Not applicable Out of Pocket $7,350
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Cost Sharing Benefits (In Network)

Policyholders are generally responsible for 100% of costs until the deductible amount is met. After the deductible has been met the policyholder is responsible for the coinsurance / copay until the out of pocket maximum is reached at which point the insurance company assumes 100% of all costs.

Deductible (Individual) $2,000
Deductible (Family) $4,000
Coinsurance Not applicable
Out of Pocket Maximum (Individual) $7,350
Out of Pocket Maximum (Family) $14,700

Doctor Visits

Primary Care Visit Data Not Available
Specialist Visit Data Not Available
Inpatient Facility 10% Coinsurance after deductible
Inpatient Physician 10% Coinsurance after deductible
Emergency Room Services $300 Copay after deductible

Tests and Imaging

Imaging (CT/PET Scans, MRIs) 25% Coinsurance after deductible
Laboratory Outpatient and Professional Services Data Not Available
X-Ray and Diagnostic Imaging 10% Coinsurance after deductible

Health Management Programs

Asthma Available
Depression Available
Diabetes Available
Heart Disease Available
High Blood Pressure / High Cholesterol Not available
Lower Back Pain Not available
Pain Management Not available
Pregnancy Available
Weight Loss Not available

Other

Mental / Behavioral Health Inpatient 10% Coinsurance after deductible
Mental / Behavioral Health Outpatient Data Not Available
Rehabilitative Speech Therapy Data Not Available
Rehabilitative Occupational & Physical Therapy Data Not Available
Outpatient Facility Data Not Available
Outpatient Surgery Data Not Available

Prescription Drugs

Generic Rx Data Not Available
Preferred Brand Rx $25 Copay after deductible
Non Preferred Brand Rx $75 Copay after deductible
Specialty Drugs 40% Coinsurance after deductible

Other Plans in Pennsylvania

Plan Silver PPO 5000/10/30 Deductible $5,000 Coinsurance Not applicable Out of Pocket $7,350
Plan Bronze PPO 7350/0/60 Deductible $7,350 Coinsurance Not applicable Out of Pocket $7,350