HNE PPO Wise 3000/10% HDHP National – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: $25 copay after deductible
Specialist visit: $50 copay after deductible
Urgent care visit: $50 copay after deductible
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | N/A N/A |
| Out-of-pocket max | N/A per person N/A 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 | $50 copay after deductible |
| Emergency room | $300 copay after deductible |
| Ambulance | $100 copay after deductible |
| Hospital stay (facility) | 10% after deductible |
| Hospital stay (physician) | No data available |
| Outpatient procedure (facility) | 10% after deductible |
| Outpatient procedure (physician) | No charge after deductible |
| Physical rehabilitation | $50 copay after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 10% 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 | 10% after deductible |
| Imaging (CT/PET/MRI) | 10% after deductible |
| Blood work | $30 copay after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $25 copay after deductible |
| Psychiatric hospital stay | 10% after deductible |
