Gold Classic, Gold, ST, INN, Circle, Wellness Rewards DP FP – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: $25 copay after deductible
Specialist visit: $40 copay after deductible
Urgent care visit: $60 copay after deductible
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $600 per person $600 per person |
| Out-of-pocket max | $5,900 per person $11,800 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $25 copay after deductible |
| Specialist visit | $40 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $60 copay after deductible |
| Emergency room | $150 copay after deductible |
| Ambulance | $150 copay after deductible |
| Hospital stay (facility) | $1,000 copay after deductible |
| Hospital stay (physician) | $100 copay after deductible |
| Outpatient procedure (facility) | $100 copay after deductible |
| Outpatient procedure (physician) | $100 copay after deductible |
| Physical rehabilitation | $30 copay after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $1,000 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | $35 copay |
| Non-preferred Brand | $70 copay |
Lab Tests and Diagnostic Procedures
| X-rays | $40 copay after deductible |
| Imaging (CT/PET/MRI) | $40 copay after deductible |
| Blood work | $40 copay after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $25 copay after deductible |
| Psychiatric hospital stay | $1,000 copay after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/vt2swZK65Vu4xfgHDv62X2YS.pdf |
