IFP Gold Plus EPO – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: $5 copay
Specialist visit: $50 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | N/A N/A |
| Out-of-pocket max | N/A per person N/A per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $5 copay |
| Specialist visit | $50 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $500 copay |
| Ambulance | 30% coinsurance |
| Hospital stay (facility) | 30% coinsurance |
| Hospital stay (physician) | $100 copay |
| Outpatient procedure (facility) | $150 copay |
| Outpatient procedure (physician) | $100 copay |
| Physical rehabilitation | $50 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 30% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | $5 copay |
| Brand | $40 copay |
| Non-preferred Brand | $200 copay |
| Specialty | 50% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | $50 copay |
| Imaging (CT/PET/MRI) | $200 copay |
| Blood work | $50 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $50 copay |
| Psychiatric hospital stay | 30% coinsurance |
