Choice Mass POS HSA $2,500/$5,000 – POS
Network type: POS
Coverage tier: Silver
Primary care visit: $30 copay after deductible
Specialist visit: $50 copay after deductible
Urgent care visit: $100 copay after deductible
Description
Health Care Plan Details
| Network type | POS |
| Deductible | See brochure See brochure |
| Out-of-pocket max | N/A per person N/A per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $30 copay after deductible |
| Specialist visit | $50 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $100 copay after deductible |
| Emergency room | $300 copay after deductible |
| Ambulance | $250 copay after deductible |
| Hospital stay (facility) | first 4 day(s) $250 per day then $0 copay after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | $250 copay after deductible |
| Outpatient procedure (physician) | No charge after deductible |
| Physical rehabilitation | $50 copay after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | first 4 day(s) $250 per day then $0 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $40 copay after deductible |
| Brand | $60 copay after deductible |
| Non-preferred Brand | 50% after deductible |
| Specialty | 50% after deductible, up to $750 copay, 50% after deductible, up to $750 |
Lab Tests and Diagnostic Procedures
| X-rays | $50 copay after deductible |
| Imaging (CT/PET/MRI) | $250 copay after deductible |
| Blood work | $25 copay after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $30 copay after deductible |
| Psychiatric hospital stay | first 4 day(s) $250 per day then $0 copay after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/h9Bz4eVFnaBbUMpuXHTsJzbe.pdf |
