Gold 2500 Legacy – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: $10 copay
Specialist visit: $60 copay
Urgent care visit: $60 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $2,500 per person $2,500 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $10 copay |
| Specialist visit | $60 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $60 copay |
| Emergency room | 10% coinsurance after deductible |
| Ambulance | 10% coinsurance after deductible |
| Hospital stay (facility) | 10% coinsurance after deductible |
| Hospital stay (physician) | 10% coinsurance after deductible |
| Outpatient procedure (facility) | 10% coinsurance after deductible |
| Outpatient procedure (physician) | 10% coinsurance after deductible |
| Physical rehabilitation | 10% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 10% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $5 copay |
| Brand | 20% coinsurance after deductible |
| Non-preferred Brand | 50% coinsurance after deductible |
| Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 10% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 10% coinsurance after deductible |
| Blood work | 10% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $10 copay |
| Psychiatric hospital stay | 10% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://regence.com/go/2024/SBC/OR/Gold2500LegacyLegacyEx |
| Drug and medication plan formulary | https://regence.com/go/2024/OR/4tier |
| Search doctor list | https://regence.com/go/OR/Legacy |
