HMO Hybrid 13, Platinum, NS, INN Adult Vision, Lasik, Wellness DP FP Dep 29 – HMO
Network type: HMO
Coverage tier: Platinum
Primary care visit: $15 copay
Specialist visit: $20 copay
Urgent care visit: $40 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $200 per person $200 per person |
| Out-of-pocket max | $7,350 per person $14,700 per family |
| Metal tier | Platinum |
Visit Copay
| Primary care visit | $15 copay |
| Specialist visit | $20 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $40 copay |
| Emergency room | 10% after deductible |
| Ambulance | 10% after deductible |
| Hospital stay (facility) | 10% after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | 10% after deductible |
| Outpatient procedure (physician) | 10% after deductible |
| Physical rehabilitation | $20 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 10% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $1 copay |
| Brand | 10% coinsurance |
| Non-preferred Brand | 40% coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | $20 copay |
| Imaging (CT/PET/MRI) | $20 copay |
| Blood work | $20 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $15 copay |
| Psychiatric hospital stay | 10% after deductible |
