HMO Copayment 14, Platinum, NS, INN, , Adult Vision, Lasik, Wellness DP FP – HMO
Network type: HMO
Coverage tier: Platinum
Primary care visit: No charge
Specialist visit: $25 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $3,000 per person $6,000 per family |
| Metal tier | Platinum |
Visit Copay
| Primary care visit | No charge |
| Specialist visit | $25 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $200 copay |
| Ambulance | $200 copay |
| Hospital stay (facility) | $250 copay |
| Hospital stay (physician) | No charge |
| Outpatient procedure (facility) | $100 copay |
| Outpatient procedure (physician) | $100 copay |
| Physical rehabilitation | $25 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $250 copay |
Pharmacy, Drugs, and Medication
| Generic | $5 copay |
| Brand | $15 copay |
| Non-preferred Brand | $45 copay |
Lab Tests and Diagnostic Procedures
| X-rays | $25 copay |
| Imaging (CT/PET/MRI) | $25 copay |
| Blood work | $25 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | No charge |
| Psychiatric hospital stay | $250 copay |
