Choice Mass POS HSA $2,500/$5,000 – POS

Description

Health Care Plan Details

Network type	POS
Deductible	See brochure See brochure
Out-of-pocket max	N/A per person N/A per family
Metal tier	Silver

Visit Copay

Primary care visit	$30 copay after deductible
Specialist visit	$50 copay after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$100 copay after deductible
Emergency room	$300 copay after deductible
Ambulance	$250 copay after deductible
Hospital stay (facility)	first 4 day(s) $250 per day then $0 copay after deductible
Hospital stay (physician)	No charge after deductible
Outpatient procedure (facility)	$250 copay after deductible
Outpatient procedure (physician)	No charge after deductible
Physical rehabilitation	$50 copay after deductible

Maternitowny and Pregnancy

Labor, delivery, hospital stay

first 4 day(s) $250 per day then $0 copay after deductible

Pharmacy, Drugs, and Medication

Generic	$40 copay after deductible
Brand	$60 copay after deductible
Non-preferred Brand	50% after deductible
Specialty	50% after deductible, up to $750 copay, 50% after deductible, up to $750

Lab Tests and Diagnostic Procedures

X-rays	$50 copay after deductible
Imaging (CT/PET/MRI)	$250 copay after deductible
Blood work	$25 copay after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$30 copay after deductible
Psychiatric hospital stay	first 4 day(s) $250 per day then $0 copay after deductible

Health Plan Provider Information

Health Plan Benefits

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