Silver Standard, Silver, ST, OON, POS, Dep29, Pediatric Dental – POS
87% cost sharing reduction [Popular Plan]
Network type: POS
Coverage tier: Silver
Primary care visit: $15 copay after deductible
Specialist visit: $35 copay after deductible
Urgent care visit: $50 copay after deductible
Description
This plan has 87% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | POS |
| Deductible | $275 per person $275 per person |
| Out-of-pocket max | $3,150 per person $6,300 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $15 copay after deductible |
| Specialist visit | $35 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay after deductible |
| Emergency room | $75 copay after deductible |
| Ambulance | $75 copay after deductible |
| Hospital stay (facility) | $250 copay per Stay after deductible |
| Hospital stay (physician) | $75 copay after deductible |
| Outpatient procedure (facility) | $75 copay after deductible |
| Outpatient procedure (physician) | $75 copay after deductible |
| Physical rehabilitation | $25 copay after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $325 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $9 copay |
| Brand | $20 copay |
| Non-preferred Brand | $40 copay |
| Specialty | No data available |
Lab Tests and Diagnostic Procedures
| X-rays | $35 copay after deductible |
| Imaging (CT/PET/MRI) | $35 copay after deductible |
| Blood work | $35 copay after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $15 copay after deductible |
| Psychiatric hospital stay | $250 copay per Stay after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://shop.highmark.com/sales/#!/sbcs/wny |
