Robin Select $5,900 w/Copay P-S Silver

20173WI0130034
Silver
PPO

Robin Select $5,900 w/Copay P-S Silver is a Silver PPO plan by HealthPartners.

IMPORTANT: You are viewing the 2024 version of Robin Select $5,900 w/Copay P-S Silver 20173WI0130034. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Robin Select $5,900 w/Copay P-S Silver is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of Robin Select $5,900 w/Copay P-S Silver 20173WI0130034.
Insurer: HealthPartners
Network Type: PPO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 20173WI0130034

Cost-Sharing Overview

Robin Select $5,900 w/Copay P-S Silver offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Robin Select $5,900 w/Copay P-S Silver?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Robin Select $5,900 w/Copay P-S Silver offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Notice Pregnancy: No
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Robin Select $5,900 w/Copay P-S Silver covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Coverage for emergency services only
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Out-of-Network benefits will be applied
National Network: No

Additional Benefits and Cost-Sharing

Robin Select $5,900 w/Copay P-S Silver includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$40.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible
Specialist Visit
Covered
$80.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$80.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Hospice Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%30.0 Days per Episode Respite care is limited to 5 days per episode, and respite and continuous care combined are limited to 30 days.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$60.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible
Home Health Care Services
Covered
$40.00 Not ApplicableNot Applicable 100.00%60.0 Visit(s) per Year
Emergency Room Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 40.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible30.0 Days per Stay days per confinement
Prenatal and Postnatal Care
Covered
No Charge Not ApplicableNot Applicable 50.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
Covered
$40.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
Covered
$40.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Generic Drugs
Covered
$20.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible
Preferred Brand Drugs
Covered
$40.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible
Non-Preferred Brand Drugs
Covered
$80.00 Copay after deductible Not ApplicableNot Applicable 50.00% Coinsurance after deductible
Specialty Drugs
Covered
$350.00 Copay after deductible Not ApplicableNot Applicable 100.00%
Outpatient Rehabilitation Services
Covered
$40.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible20.0 Visit(s) per Year
Habilitation Services
Covered
$40.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible20.0 Visit(s) per Year
Chiropractic Care
Covered
$80.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible
Durable Medical Equipment
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Hearing Aids
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible1.0 Item(s) per 3 Years
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
Covered
Not Applicable 0.00%Not Applicable 50.00% Coinsurance after deductible
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge Not ApplicableNot Applicable 50.00% Coinsurance after deductible
Eye Glasses for Children
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%1.0 Item(s) per Year Limited to one pair of eyeglasses (lenses and frames), or one pair of contact lenses per calendar year
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$40.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible20.0 Visit(s) per Year
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$40.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible20.0 Visit(s) per Year
Well Baby Visits and Care
Covered
No Charge Not ApplicableNot Applicable 50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Accidental Dental
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Dialysis
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Allergy Testing
Covered
$80.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible
Chemotherapy
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Radiation
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Diabetes Education
Covered
No Charge Not ApplicableNot Applicable 50.00% Coinsurance after deductible
Prosthetic Devices
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Infusion Therapy
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Nutritional Counseling
Covered
No Charge Not ApplicableNot Applicable 50.00% Coinsurance after deductible
Reconstructive Surgery
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Gender Affirming Care
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible

Free Preventive Services

There is no copayment or coinsurance for any of the following Robin Select $5,900 w/Copay P-S Silver preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Robin Select $5,900 w/Copay P-S Silver including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Robin Select $5,900 w/Copay P-S Silver?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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