IHC Silver EPO Local Value $5/$20 – EPO
94% cost sharing reduction [Popular Plan]
Network type: EPO
Coverage tier: Silver
Primary care visit: $5 copay after deductible
Specialist visit: $20 copay after deductible
Urgent care visit: $85 copay after deductible
Description
This plan has 94% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | EPO |
| Deductible | $50 per person $50 per person |
| Out-of-pocket max | $1,000 per person $2,000 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $5 copay after deductible |
| Specialist visit | $20 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $85 copay after deductible |
| Emergency room | $100 copay after deductible |
| Ambulance | 50% after deductible |
| Hospital stay (facility) | first 5 day(s) $200 per day after deductible copay |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | 10% after deductible |
| Outpatient procedure (physician) | 10% after deductible |
| Physical rehabilitation | $20 copay after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | first 5 day(s) $200 per day after deductible copay |
Pharmacy, Drugs, and Medication
| Generic | $5 copay after deductible |
| Brand | 50% after deductible |
| Non-preferred Brand | 50% after deductible |
| Specialty | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $50 copay after deductible |
| Imaging (CT/PET/MRI) | $100 copay after deductible |
| Blood work | No charge after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $20 copay after deductible |
| Psychiatric hospital stay | first 5 day(s) $200 per day after deductible copay |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/dujgbo4FrhzEnaA343Q54phE.pdf |
