Silver Plans

Cost-Sharing and Lower Premium

The benefit levels of our HMO Silver Plan are the same as our HMO Gold plans, but with greater cost-sharing for your employees.
 
This means lower premiums and greater overall savings; plus, this plan allows your employees to take advantage of the wide variety of local providers and services included in the FirstCare network.

Call us today to learn more about enrollment timeframes and to find a plan that fits your needs. 1-855-572-7238.

 

Glance through the chart below for a comparison, or open up the linked PDFs for more details.

 Print
2017
Plan Benefits
Select Network
HMO
Silver
Coinsurance 3100
HMO
Silver
Coinsurance 4500
HMO
Silver
Copay
HMO
Silver
HSA (100%)
Medical Deductible (if any)
Single/Family
$3,100/$6,200 $4,500/$9,000 $3,700/$7,400 $3,750/$7,500
Medication Deductible (if any) 
Single/Family
$0/$0 $0/$0 $0/$0 Integrated with Medical
Preventive Care Copay No Charge No Charge No Charge No Charge
Adult Primary Care Visit Copay $25 $25
$25
 
0%1
Pediatric Primary Care Visit Copay (Ages 0-19) No Charge No Charge No Charge 0%1
Specialty Care Visit Copay $50 $50 $50
0%1
Inpatient Copay 20%1 20%1 $600 copay per day1, not to exceed $3,000 per stay 0%1
Outpatient Copay 20%1 20%1 $600 copay1 0%1
Emergency Room Copay $5001 $5001
$5001
 
0%1
Urgent Care Copay $50 $50 $50 0%1
Routine Lab/X-Ray Copay No Charge No Charge
No Charge
 
0%1
Imaging (MRI, CT, Scans) Copay $250 per test1 $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
$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 $6,850/$13,700
$3,750/$7,500
 
Plan ID 26539TX0130003-
00
26539TX0130017-
00
26539TX0130006-
00
26539TX0130016-
00
Summary of Benefits & Coverage
(SBC)
Plan Documents
1After Medical Deductible
 
 Print
2017
Plan Benefits
Select Plus Network
HMO
Silver Coinsurance 3100
HMO
Silver Coinsurance 4500
HMO
Silver Copay
HMO
Silver HSA (100%)
Medical Deductible (if any)
Single/Family
$3,100/$6,200 $4,500/$9,000 $3,700/$7,400 $3,750/$7,500
Medication Deductible (if any) 
Single/Family
$0/$0 $0/$0 $0/$0 Integrated with Medical
Preventive Care Copay No Charge No Charge No Charge No Charge 
Adult Primary Care Visit Copay $25 $25 $25 0%1
Pediatric Primary Care Visit Copay (Ages 0-19) No Charge No Charge No Charge 0%1
Specialty Care Visit Copay $50 $50 $50 0%1
Inpatient Copay 20%1 20%1 $600 copay per day1, not to exceed $3,000 per stay 0%1
Outpatient Copay 20%1 20%1 $600 copay1 0%1
Emergency Room Copay $5001 $5001 $5001 0%1
Urgent Care Copay $50 $50 $50 0%1
Routine Lab/X-Ray Copay No Charge No Charge No Charge 0%1
Imaging (MRI, CT, Scans) Copay $250 per test1 $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
$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 $6,850/$13,700 $3,750/$7,500
Plan ID 26539TX0130010-
00
26539TX0130019-
00
26539TX0130011-
00
26539TX0130015-
00
Summary of Benefits & Coverage
(SBC)
Plan Documents
1After Medical Deductible



 

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