HDHMO HSA Qualified 33, Silver, NS, INN Adult Vision, Lasik, Wellness DP FP Dep 29 – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: 15% after deductible
Specialist visit: 15% after deductible
Urgent care visit: 15% after deductible
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $3,500 per person $3,500 per person |
| Out-of-pocket max | $7,000 per person $14,000 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | 15% after deductible |
| Specialist visit | 15% after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | 15% after deductible |
| Emergency room | 15% after deductible |
| Ambulance | 15% after deductible |
| Hospital stay (facility) | 15% after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | 15% after deductible |
| Outpatient procedure (physician) | 15% after deductible |
| Physical rehabilitation | 15% after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 15% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $4 copay after deductible |
| Brand | 50% after deductible |
| Non-preferred Brand | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 15% after deductible |
| Imaging (CT/PET/MRI) | 15% after deductible |
| Blood work | 15% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 15% after deductible |
| Psychiatric hospital stay | 15% after deductible |
