Complete Silver + Vision + Adult Dental
SilverSummit Healthplan, Inc. · 2027 plan year
Silver
- Ind. deductible
- $0
- Family deductible
- $0
- Ind. OOP max
- $2,700
- Family OOP max
- $5,400
Other cost-sharing reduction variants for this plan:
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Benefits & cost sharing
Primary Care
| Benefit | In-network |
|---|---|
| Preventive Care/Screening/Immunization | No charge |
| Primary Care Visit to Treat an Injury or Illness | No charge |
Specialist
| Benefit | In-network |
|---|---|
| Specialist Visit | $10.00 |
Hospital
| Benefit | In-network |
|---|---|
| Emergency Room Services | 25.00% |
| Inpatient Hospital Services (e.g., Hospital Stay) | 25.00% |
| Mental/Behavioral Health Emergency Room | 25.00% |
| Mental/Behavioral Health Urgent Care | No charge |
| Outpatient Surgery Physician/Surgical Services | 25.00% |
| Substance Use Disorder Emergency Room | 25.00% |
| Substance Use Disorder Urgent Care | No charge |
| Urgent Care Centers or Facilities | $10.00 |
Pharmacy
| Benefit | In-network |
|---|---|
| Generic Drugs | No charge |
| Non-Preferred Brand Drugs | 30.00% |
| Preferred Brand Drugs | $30.00 |
| Specialty Drugs | 35.00% |
| Tier 1b Generic Drugs | No charge |
Mental Health
| Benefit | In-network |
|---|---|
| Mental/Behavioral Health Emergency Transportation/Ambulance | 25.00% |
| Mental/Behavioral Health ER Physician Fee | 25.00% |
| Mental/Behavioral Health Inpatient Services | 25.00% |
| Mental/Behavioral Health Outpatient Other Services | No charge |
| Mental/Behavioral Health Outpatient Services | No charge |
| Substance Use Disorder Emergency Transportation/Ambulance | 25.00% |
| Substance Use Disorder ER Physician Fee | 25.00% |
| Substance Use Disorder Outpatient Other Services | No charge |
Other
| Benefit | In-network |
|---|---|
| Accidental Dental | 25.00% |
| Allergy Testing | $10.00 |
| Bariatric Surgery | 25.00% |
| Basic Dental Care - Adult | 50.00% |
| Chemotherapy | 25.00% |
| Chiropractic Care | 25.00% |
| Delivery and All Inpatient Services for Maternity Care | 25.00% |
| Diabetes Education | 25.00% |
| Dialysis | 25.00% |
| Durable Medical Equipment | 25.00% |
| Emergency Transportation/Ambulance | 25.00% |
| Eye Glasses for Children | No charge |
| Gender Affirming Care | 25.00% |
| Habilitation Services | 25.00% |
| Hearing Aids | 25.00% |
| Home Health Care Services | 25.00% |
| Hospice Services | 25.00% |
| Imaging (CT/PET Scans, MRIs) | 25.00% |
| Infertility Treatment | 25.00% |
| Infusion Therapy | 25.00% |
| Inpatient Physician and Surgical Services | 25.00% |
| Laboratory Outpatient and Professional Services | No charge |
| Major Dental Care - Adult | 50.00% |
| Nutritional Counseling | $10.00 |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | No charge |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 25.00% |
| Outpatient Rehabilitation Services | 25.00% |
| Prenatal and Postnatal Care | No charge |
| Private-Duty Nursing | 25.00% |
| Prosthetic Devices | 25.00% |
| Radiation | 25.00% |
| Reconstructive Surgery | 25.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | 25.00% |
| Rehabilitative Speech Therapy | 25.00% |
| Routine Dental Services (Adult) | No charge |
| Routine Eye Exam (Adult) | No charge |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | $10.00 |
| Skilled Nursing Facility | 25.00% |
| Substance Abuse Disorder Inpatient Services | 25.00% |
| Substance Abuse Disorder Outpatient Services | No charge |
| Transplant | 25.00% |
| Treatment for Temporomandibular Joint Disorders | 25.00% |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | 25.00% |
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