HMO Copayment 30, Silver, ST, INN DP FP – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $30 copay after deductible
Specialist visit: $65 copay after deductible
Urgent care visit: $70 copay after deductible
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $2,100 per person $2,100 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $30 copay after deductible |
| Specialist visit | $65 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $70 copay after deductible |
| Emergency room | $500 copay after deductible |
| Ambulance | $150 copay after deductible |
| Hospital stay (facility) | $1,500 copay after deductible |
| Hospital stay (physician) | $150 copay after deductible |
| Outpatient procedure (facility) | $150 copay after deductible |
| Outpatient procedure (physician) | $150 copay after deductible |
| Physical rehabilitation | $30 copay after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $1,650 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $15 copay |
| Brand | $40 copay |
| Non-preferred Brand | $75 copay |
Lab Tests and Diagnostic Procedures
| X-rays | $75 copay after deductible |
| Imaging (CT/PET/MRI) | $175 copay after deductible |
| Blood work | $50 copay after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $30 copay after deductible |
| Psychiatric hospital stay | $1,500 copay after deductible |
