Silver Plans
For details on our 2017 Silver Plans, see below:
2017
Plan Benefits
Access PPO |
PPO
Silver
Coinsurance 3100 |
PPO
Silver
Coinsurance 4500 |
PPO
Silver
HSA (100%) |
Medical Deductible (if any)
Single/Family |
$3,100/$6,200 |
$4,500/$9,000 |
$3,750/$7,500 |
Medication Deductible (if any)
Single/Family |
$0/$0 |
$0/$0 |
Integrated with Medical |
| Preventive Care Copay |
No Charge |
No Charge |
No Charge |
| Adult Primary Care Visit Copay |
$25 |
$25 |
0%1 |
Pediatric Primary Care Visit Copay
(Ages 0-19) |
No Charge |
No Charge |
0%1 |
| Specialty Care Visit Copay |
$50 |
$50 |
0%1 |
| Inpatient Copay |
20%1 |
20%1 |
0%1 |
| Outpatient Copay |
20%1 |
20%1 |
0%1 |
| Emergency Room Copay |
$5001 |
$5001 |
0%1 |
| Urgent Care Copay |
$50 |
$50 |
0%1 |
| Routine Lab/X-Ray Copay |
No Charge |
No Charge |
0%1 |
| Imaging (MRI, CT, Scans) Copay |
$250 per test1 |
$250 per test1 |
0%1 |
Medication Copays:
Tier I
Tier II
Tier III
Tier IV
Tier V |
$0
$20
$50
$100
40%
|
$0
$10
$50
$100
40%
|
0%1
0%1
0%1
0%1
0%1
|
Maximum Out-Of-Pocket
Single/Family |
$7,150/$14,300 |
$6,000/$12,000 |
$3,750/$7,500 |
| Plan ID |
41549X0110001-00 |
41549X0110003-00 |
41549X0110002-00 |
Summary of Benefits & Coverage
(SBC) |
 |
|
|
| Plan Documents |
|
|
|
1After Medical Deductible
2017
Plan Benefits
FirstCare MyChoice™ PPO |
PPO
Silver
Coinsurance 2700 |
PPO
Silver
Coinsurance 4500 |
PPO
Silver
HSA (100%) |
Medical Deductible (if any)
Single/Family |
$2,700/$5,400 |
$4,500/$9,000 |
$3,250/$6,500 |
Medication Deductible (if any)
Single/Family |
$0/$0 |
$0/$0 |
Integrated with Medical |
| Preventive Care Copay |
No Charge |
No Charge |
No Charge |
| Adult Primary Care Visit Copay |
$25 |
$25 |
0%1 |
Pediatric Primary Care Visit Copay
(Ages 0-19) |
No Charge |
No Charge |
0%1 |
| Specialty Care Visit Copay |
$50 |
$50 |
0%1
|
| Inpatient Copay |
20%1 |
20%1 |
0%1 |
| Outpatient Copay |
20%1 |
20%1 |
0%1 |
| Emergency Room Copay |
$5001 |
$5001 |
0%1 |
| Urgent Care Copay |
$50 |
$50 |
0%1 |
| Routine Lab/X-Ray Copay |
No Charge |
No Charge |
0%1 |
| Imaging (MRI, CT, Scans) Copay |
$200 per test1 |
$200 per test1 |
0%1 |
Medication Copays:
Tier I
Tier II
Tier III
Tier IV
Tier V |
$0
$20
$50
$100
40%
|
$0
$20
$50
$100
40%
|
0%1
0%1
0%1
0%1
0%1
|
Maximum Out-Of-Pocket
Single/Family |
$7,150/$14,300 |
$6,000/$12,000 |
$3,250/$6,500
|
| Plan ID |
41549X0110004-00 |
41549TX0110005-00 |
41549TX0110006-00 |
Summary of Benefits & Coverage
(SBC) |
|
|
|
| Plan Documents |
|
|
|
1After Medical Deductible