HNE Essential 3000 – HMO

Network type: HMO
Coverage tier: Gold
Primary care visit: $25 copay
Specialist visit: $40 copay
Urgent care visit: $40 copay

SKU: 34484MA2080001 Category:

Description

Health Care Plan Details

Network type HMO
Deductible N/A N/A
Out-of-pocket max N/A per person N/A per family
Metal tier Gold

Visit Copay

Primary care visit $25 copay
Specialist visit $40 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $40 copay
Emergency room $500 copay after deductible
Ambulance $100 copay after deductible
Hospital stay (facility) $100 copay after deductible
Hospital stay (physician) No charge after deductible
Outpatient procedure (facility) $100 copay after deductible
Outpatient procedure (physician) No charge after deductible
Physical rehabilitation $40 copay after deductible

Maternitowny and Pregnancy

Labor, delivery, hospital stay $100 copay after deductible

Pharmacy, Drugs, and Medication

Generic $30 copay
Brand $80 copay
Non-preferred Brand $125 copay
Specialty $150 copay

Lab Tests and Diagnostic Procedures

X-rays $50 copay after deductible
Imaging (CT/PET/MRI) $300 copay after deductible
Blood work $40 copay

Mental and Psychiatric Health Care

Mental Health outpatient services $25 copay
Psychiatric hospital stay $100 copay after deductible

Health Plan Provider Information