Catastrophic 1746 (Primary Care Copay Visits 1-3, Open Access)

Health First Commercial Plans, Inc.

CatastrophicHSA eligible

Ind. deductible: $10,600
Family deductible: $10,600
Ind. OOP max: $10,600
Family OOP max: $10,600

Other cost-sharing reduction variants for this plan:

Monthly premiums by age

Age	Individual	Individual + tobacco
21	$260	—
30	$295	—
40	$332	—
50	$464	—
60	$706	—

Live premium estimate

Benefits & cost sharing

Primary Care

Benefit	In-network
Preventive Care/Screening/Immunization	No charge
Primary Care Visit to Treat an Injury or Illness	$35.00

Specialist

Benefit	In-network
Specialist Visit	0.00% Coinsurance after deductible

Hospital

Benefit	In-network
Emergency Room Services	0.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	0.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services	0.00% Coinsurance after deductible
Urgent Care Centers or Facilities	0.00% Coinsurance after deductible

Pharmacy

Benefit	In-network
Generic Drugs	0.00% Coinsurance after deductible
Non-Preferred Brand Drugs	0.00% Coinsurance after deductible
Preferred Brand Drugs	0.00% Coinsurance after deductible
Preferred Generic Drugs	0.00% Coinsurance after deductible
Specialty Drugs	0.00% Coinsurance after deductible

Mental Health

Benefit	In-network
Mental Health Office Visit	0.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services	0.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services	0.00% Coinsurance after deductible

Other

Benefit	In-network
Abortion for Which Public Funding is Prohibited	Not covered
Accidental Dental	0.00% Coinsurance after deductible
Acupuncture	Not covered
Allergy Testing	0.00% Coinsurance after deductible
Anesthesia Services for Dental Care	0.00% Coinsurance after deductible
Bariatric Surgery	Not covered
Basic Dental Care - Adult	Not covered
Basic Dental Care - Child	0.00% Coinsurance after deductible
Cardiac and Pulmonary Rehabilitation	0.00% Coinsurance after deductible
Chemotherapy	0.00% Coinsurance after deductible
Chiropractic Care	0.00% Coinsurance after deductible
Cosmetic Surgery	Not covered
Delivery and All Inpatient Services for Maternity Care	0.00% Coinsurance after deductible
Dental Check-Up for Children	0.00% Coinsurance after deductible
Diabetes Education	No charge
Dialysis	0.00% Coinsurance after deductible
Durable Medical Equipment	0.00% Coinsurance after deductible
Emergency Transportation/Ambulance	0.00% Coinsurance after deductible
Enteral/Parenteral and Oral Nutrition Therapy	0.00% Coinsurance after deductible
Eye Glasses for Adult	Not covered
Eye Glasses for Children	0.00% Coinsurance after deductible
Genetic Testing Lab Services	0.00% Coinsurance after deductible
Habilitation Services	0.00% Coinsurance after deductible
Hearing Aids	Not covered
Home Health Care Services	0.00% Coinsurance after deductible
Hospice Services	0.00% Coinsurance after deductible
Hyperbaric Oxygen Therapy	0.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)	0.00% Coinsurance after deductible
Infertility Treatment	Not covered
Infusion Therapy	0.00% Coinsurance after deductible
Inpatient Physician and Surgical Services	0.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services	0.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care	Not covered
Major Dental Care - Adult	Not covered
Major Dental Care - Child	0.00% Coinsurance after deductible
Nutritional Counseling	No charge
Orthodontia - Adult	Not covered
Orthodontia - Child	0.00% Coinsurance after deductible
Osteoporosis Treatment	0.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)	$35.00
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	0.00% Coinsurance after deductible
Outpatient Observation	0.00% Coinsurance after deductible
Outpatient Rehabilitation Services	0.00% Coinsurance after deductible
Partial Hospitalization	0.00% Coinsurance after deductible
Prenatal and Postnatal Care	No charge
Private-Duty Nursing	Not covered
Prosthetic Devices	0.00% Coinsurance after deductible
Radiation	0.00% Coinsurance after deductible
Reconstructive Surgery	0.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy	0.00% Coinsurance after deductible
Rehabilitative Speech Therapy	0.00% Coinsurance after deductible
Routine Dental Services (Adult)	Not covered
Routine Eye Exam (Adult)	Not covered
Routine Eye Exam for Children	0.00% Coinsurance after deductible
Routine Foot Care	0.00% Coinsurance after deductible
Skilled Nursing Facility	0.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services	0.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services	0.00% Coinsurance after deductible
Substance Abuse Office Visit	0.00% Coinsurance after deductible
Transplant	0.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders	0.00% Coinsurance after deductible
Weight Loss Programs	Not covered
Well Baby Visits and Care	No charge
X-rays and Diagnostic Imaging	0.00% Coinsurance after deductible

Plan rules

Service area

This plan covers 5 geographic areas.