Presbyterian Health Plan, Inc*

Presbyterian Health Plan, Inc* | Individual HMO Silver 3 w/Gym Membership

  • Individual HMO Silver 3 w/Gym Membership is an Obamacare health insurance plan offered by Presbyterian Health Plan, Inc* that is available for individuals and families.

  • This plan is a HMO, meaning you will have to stay within the insurance company’s network, and will need to see a primary care doctor first and get a referral in order to see a specialist. (Read more about HMOs.)

  • This plan is a Silver metal level plan, which generally has a mid-level monthly cost and deductible (and co-pay), and provides middle-of-the-road insurance coverage for people who occasionally use their health care benefits (doctors, prescription drugs, etc.).

  • Deductible amount of $3,000. A deductible is the amount of healthcare costs you will pay on your own each year before the insurance company.

  • Max out-of-pocket of $6,850, which is the most you will pay in a plan year outside of premiums, out-of-network providers and non-essential health benefits.


Ways to Enroll or Learn More

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Plan Summary

Monthly Cost

Plan Name:
Individual HMO Silver 3 w/Gym Membership

Plan ID:
57173NM0310003

Plan Type:
HMO

Deductible:
$3,000

Maximum Out-of-Pocket:
$6,850

Summary of Benefits:

Provider Information:

Who is this plan for?

This plan with a moderate monthly cost is great for individuals and families who occasionally visit the doctor or use prescription drugs. The moderate deductible on this plan means you will pay a fair amount of money out of pocket for medical care and prescriptions before your insurance kicks in. The very high out-of-pocket maximum on this plan means you could be faced with a very expensive medical bill if an emergency happens. Plans with this type of provider network tend to have a narrower provider network.

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Highlights


Emergency Room:
$250

Retail Drugs:
$75

Generic Drugs:
$15

Overview


Plan Type:
HMO

Metal Level:
Silver

Health Spending Account:
No

Primary Care Office Visit:
$10

Specialist Office Visit:
$50

Out of Network Coverage:
Yes

Out of Country Coverage:
Yes

Coverage Details

Preventive Care

Periodic Health Exam
In Network:
No Charge

Out of Network:
Not Covered
Well Baby Care
In Network:
No Charge

Out of Network:
Not Covered

Inpatient

Hospital Services
In Network:
20% Coinsurance after deductible

Out of Network:
Not Covered
Physician Fee
In Network:
20% Coinsurance after deductible

Out of Network:
Not Covered
Skilled Nursing Facility
In Network:
$50 Copay per Day

Out of Network:
Not Covered
Mental Health
In Network:
20% Coinsurance after deductible

Out of Network:
Not Covered
Substance Abuse
In Network:
20% Coinsurance after deductible

Out of Network:
Not Covered
Home Healthcare
In Network:
20% Coinsurance after deductible

Out of Network:
Not Covered

Outpatient

Surgery
In Network:
20% Coinsurance after deductible

Out of Network:
Not Covered
X-ray and Diagnostics
In Network:
No Charge

Out of Network:
Not Covered
Labs
In Network:
No Charge

Out of Network:
Not Covered
Facility Fee
In Network:
20% Coinsurance after deductible

Out of Network:
Not Covered
Mental Health
In Network:
$10

Out of Network:
Not Covered
Substance Abuse
In Network:
$10

Out of Network:
Not Covered
Rehabilitation Services
In Network:
20% Coinsurance after deductible

Out of Network:
Not Covered

Maternity/Pregnancy

Pre & Postnatal Care
In Network:
$300

Out of Network:
Not Covered
Infertility Treatment
In Network:
20% Coinsurance after deductible

Out of Network:
Not Covered
Labor and Delivery Inpatient Services
In Network:
20% Coinsurance after deductible

Out of Network:
Not Covered

Dental

Accidental Care
In Network:
20% Coinsurance after deductible

Out of Network:
Not Covered

Vision

Eye Exam (Child)
In Network:
No Charge

Out of Network:
50%
Glasses (Child)
In Network:
No Charge

Out of Network:
50%

Additional Coverage

Chiropractic Care
In Network:
20% Coinsurance after deductible

Out of Network:
Not Covered
Habilitation Services
In Network:
20% Coinsurance after deductible

Out of Network:
Not Covered
Rehabilitation Services (Speech)
In Network:
$50

Out of Network:
Not Covered
Rehabilitation Services (Occupational Therapy)
In Network:
$50

Out of Network:
Not Covered
Hospice Service
In Network:
20% Coinsurance after deductible

Out of Network:
Not Covered
Diabetes Care Management
In Network:
20% Coinsurance after deductible

Out of Network:
Not Covered
Durable Medical Equipment
In Network:
20% Coinsurance after deductible

Out of Network:
Not Covered
Hearing Aids
In Network:
20% Coinsurance after deductible

Out of Network:
Not Covered
Nutritional Consuleling
In Network:
20% Coinsurance after deductible

Out of Network:
Not Covered
Reconstructive Surgery
In Network:
20% Coinsurance after deductible

Out of Network:
Not Covered
Outside US Non-emergency Care
In Network:
20% Coinsurance after deductible

Out of Network:
Not Covered

Doctor Visits

Primary Care Visit
In Network:
$10

Out of Network:
Not Covered
Specialist Visit
In Network:
$50

Out of Network:
Not Covered
Other Practitioner Office Visit
In Network:
$10

Out of Network:
Not Covered
Preventative Care / Screening / Immunization
In Network:
No Charge

Out of Network:
Not Covered

Emergency Room and Urgent Care

Emergency Room Services
In Network:
$250

Out of Network:
$250
Urgent Care Services
In Network:
$50

Out of Network:
Not Covered
Ambulance/Transportation Services
In Network:
20% Coinsurance after deductible

Out of Network:
20% Coinsurance after deductible

Drugs

Generic Prescription
In Network:
$15

Out of Network:
$15
Retail Brand Drugs
In Network:
$75

Out of Network:
$75
Non Retail Brand Drugs
In Network:
$125

Out of Network:
$125
Specialty Drugs
In Network:
50% Coinsurance after deductible

Out of Network:
50% Coinsurance after deductible

Additional Plan Information

Summary Of Benefits:

Provider Information:

HealthCare.com is a privately owned website, and monthly costs shown above are estimates only. Your monthly premium may change based on the data provided, outside fees, optional benefits or if other factors take effect before your coverage start date. Note that insurance companies reserve the right to change your premium rate and the policy terms at any time. Effective date, benefit amounts and other conditions may apply at the discretion of the insurance carrier you select. Depending on your state of residence, this website may not display all plans available by state. The Obamacare Tax Subsidy Calculator amounts are estimates only and the actual amount of subsidy eligibility may differ. Access to your physician depends on network selected, and networks can change without notice. Contact your health insurance company to confirm your healthcare provider is still available in the network you select.

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