Capital - Silver PPO 5000/10/30

Pennsylvania, 2019

  • Plan Type

    PPO

  • Metal Tier

    Silver

  • Out of Pocket Maximum

    $7,350

  • Deductible

    $5,000

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) $5,000
Deductible (Family) $10,000
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 $400 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 $50 Copay after deductible
Non Preferred Brand Rx $100 Copay after deductible
Specialty Drugs 50% Coinsurance after deductible

73% Cost Sharing Benefits

Households with incomes between 200% to 250% of FPL qualify for the following cost sharing benefits for this silver plan. To understand how cost sharing reductions work and how they work for you see our article about Obamacare Cost Sharing Reduction Discounts

Deductibles and Cost Sharing

Deductible (Individual) $4,500
Deductible (Family) $9,000
Out of Pocket Maximum (Individual) $5,850
Out of Pocket Maximum (Family) $11,700

Doctor Visits

Primary Care Physician
Specialists
Emergency Room $200 Copay after deductible
Inpatient Facility 8% Coinsurance after deductible
Inpatient Physician 8% Coinsurance after deductible

Prescription Drugs

Generic Rx
Preferred Brand Rx $25 Copay after deductible
Non Preferred Brand Rx $55 Copay after deductible
Specialty Drugs 40% Coinsurance after deductible

87% Cost Sharing Benefits

Households with incomes between 150% to 200% of FPL qualify for the following cost sharing benefits for this silver plan.

Deductibles and Cost Sharing

Deductible (Individual) $1,200
Deductible (Family) $2,400
Out of Pocket Maximum (Individual) $2,450
Out of Pocket Maximum (Family) $4,900

Doctor Visits

Primary Care Physician
Specialists
Emergency Room $75 Copay after deductible
Inpatient Facility 5% Coinsurance after deductible
Inpatient Physician 5% Coinsurance after deductible

Prescription Drugs

Generic Rx
Preferred Brand Rx $15 Copay after deductible
Non Preferred Brand Rx $40 Copay after deductible
Specialty Drugs 30% Coinsurance after deductible

94% Cost Sharing Benefits

Households with incomes between 138% to 150% of FPL qualify for the following cost sharing benefits for this silver plan.

Deductibles and Cost Sharing

Deductible (Individual) $250
Deductible (Family) $500
Out of Pocket Maximum (Individual) $1,250
Out of Pocket Maximum (Family) $2,500

Doctor Visits

Primary Care Physician
Specialists
Emergency Room $50 Copay after deductible
Inpatient Facility No charge after deductible
Inpatient Physician No charge after deductible

Prescription Drugs

Generic Rx
Preferred Brand Rx $10 Copay after deductible
Non Preferred Brand Rx $25 Copay after deductible
Specialty Drugs 10% Coinsurance after deductible

Other Plans in Pennsylvania

Plan Gold PPO 2000/10/20 Deductible $2,000 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) $5,000
Deductible (Family) $10,000
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 $400 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 $50 Copay after deductible
Non Preferred Brand Rx $100 Copay after deductible
Specialty Drugs 50% Coinsurance after deductible

73% Cost Sharing Benefits

Households with incomes between 200% to 250% of FPL qualify for the following cost sharing benefits for this silver plan. To understand how cost sharing reductions work and how they work for you see our article about Obamacare Cost Sharing Reduction Discounts

Deductibles and Cost Sharing

Deductible (Individual) $4,500
Deductible (Family) $9,000
Out of Pocket Maximum (Individual) $5,850
Out of Pocket Maximum (Family) $11,700

Doctor Visits

Primary Care Physician
Specialists
Emergency Room $200 Copay after deductible
Inpatient Facility 8% Coinsurance after deductible
Inpatient Physician 8% Coinsurance after deductible

Prescription Drugs

Generic Rx
Preferred Brand Rx $25 Copay after deductible
Non Preferred Brand Rx $55 Copay after deductible
Specialty Drugs 40% Coinsurance after deductible

87% Cost Sharing Benefits

Households with incomes between 150% to 200% of FPL qualify for the following cost sharing benefits for this silver plan.

Deductibles and Cost Sharing

Deductible (Individual) $1,200
Deductible (Family) $2,400
Out of Pocket Maximum (Individual) $2,450
Out of Pocket Maximum (Family) $4,900

Doctor Visits

Primary Care Physician
Specialists
Emergency Room $75 Copay after deductible
Inpatient Facility 5% Coinsurance after deductible
Inpatient Physician 5% Coinsurance after deductible

Prescription Drugs

Generic Rx
Preferred Brand Rx $15 Copay after deductible
Non Preferred Brand Rx $40 Copay after deductible
Specialty Drugs 30% Coinsurance after deductible

94% Cost Sharing Benefits

Households with incomes between 138% to 150% of FPL qualify for the following cost sharing benefits for this silver plan.

Deductibles and Cost Sharing

Deductible (Individual) $250
Deductible (Family) $500
Out of Pocket Maximum (Individual) $1,250
Out of Pocket Maximum (Family) $2,500

Doctor Visits

Primary Care Physician
Specialists
Emergency Room $50 Copay after deductible
Inpatient Facility No charge after deductible
Inpatient Physician No charge after deductible

Prescription Drugs

Generic Rx
Preferred Brand Rx $10 Copay after deductible
Non Preferred Brand Rx $25 Copay after deductible
Specialty Drugs 10% Coinsurance after deductible

Other Plans in Pennsylvania

Plan Gold PPO 2000/10/20 Deductible $2,000 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