Activate Gold NS OON IHC Network DP FP Dep 29 – POS
Network type: POS
Coverage tier: Gold
Primary care visit: $20 copay after deductible
Specialist visit: $50 copay after deductible
Urgent care visit: $75 copay after deductible
Description
Health Care Plan Details
| Network type | POS |
| 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 | $20 copay after deductible |
| Specialist visit | $50 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay after deductible |
| Emergency room | 25% after deductible |
| Ambulance | 25% after deductible |
| Hospital stay (facility) | 25% after deductible |
| Hospital stay (physician) | 25% after deductible |
| Outpatient procedure (facility) | 25% after deductible |
| Outpatient procedure (physician) | 25% after deductible |
| Physical rehabilitation | $50 copay after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 25% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 copay after deductible |
| Brand | 25% after deductible |
| Non-preferred Brand | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $50 copay after deductible |
| Imaging (CT/PET/MRI) | $85 copay after deductible |
| Blood work | $20 copay after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | No charge after deductible |
| Psychiatric hospital stay | 25% after deductible |