IFP ON Silver 20 PCP HMO – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $20 copay after deductible
Specialist visit: $80 copay after deductible
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $4,590 per person $4,590 per person |
| Out-of-pocket max | $9,180 per person $18,360 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $20 copay after deductible |
| Specialist visit | $80 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | 50% after deductible |
| Ambulance | 50% after deductible |
| Hospital stay (facility) | 50% after deductible |
| Hospital stay (physician) | 50% after deductible |
| Outpatient procedure (facility) | 50% after deductible |
| Outpatient procedure (physician) | 50% after deductible |
| Physical rehabilitation | $80 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 50% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $15 copay |
| Brand | $65 copay |
| Non-preferred Brand | 50% after deductible |
| Specialty | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 50% after deductible |
| Imaging (CT/PET/MRI) | 50% after deductible |
| Blood work | 50% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 50% after deductible |
| Psychiatric hospital stay | 50% after deductible |
