HDHMO HSA Qualified 35 Silver, NS, INN, Adult Vision, Lasik, Wellness DP FP – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $25 copay after deductible
Specialist visit: $50 copay after deductible
Urgent care visit: $75 copay after deductible
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $2,500 per person $2,500 per person |
| Out-of-pocket max | $7,050 per person $14,100 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $25 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 | $500 copay after deductible |
| Ambulance | $500 copay after deductible |
| Hospital stay (facility) | $1,500 copay after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | $200 copay after deductible |
| Outpatient procedure (physician) | $100 copay after deductible |
| Physical rehabilitation | $50 copay after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $1,500 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 copay after deductible |
| Brand | $50 copay after deductible |
| Non-preferred Brand | $80 copay after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $50 copay after deductible |
| Imaging (CT/PET/MRI) | $50 copay after deductible |
| Blood work | $50 copay after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $25 copay after deductible |
| Psychiatric hospital stay | $1,500 copay after deductible |
