HMO Triple Zero Copayment 24, Gold, NS, INN Adult Vision, Lasik, Wellness DP FP Dep 29 – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $50 copay
Specialist visit: $50 copay
Urgent care visit: $100 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $8,700 per person $17,400 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $50 copay |
| Specialist visit | $50 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $100 copay |
| Emergency room | $500 copay |
| Ambulance | $500 copay |
| Hospital stay (facility) | $1,500 copay |
| Hospital stay (physician) | No charge |
| Outpatient procedure (facility) | $250 copay |
| Outpatient procedure (physician) | $100 copay |
| Physical rehabilitation | $50 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $1,500 copay |
Pharmacy, Drugs, and Medication
| Generic | No charge |
| Brand | $50 copay |
| Non-preferred Brand | $80 copay |
Lab Tests and Diagnostic Procedures
| X-rays | $50 copay |
| Imaging (CT/PET/MRI) | $50 copay |
| Blood work | $50 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $50 copay |
| Psychiatric hospital stay | $1,500 copay |
