IFP Silver 70 HSA ON – HMO

Network type: HMO
Coverage tier: Silver
Primary care visit: No charge after deductible
Specialist visit: $80 copay after deductible
Urgent care visit: $50 copay after deductible

Description

Health Care Plan Details

Network type HMO
Deductible $3,295 per person $3,295 per person
Out-of-pocket max $6,590 per person $13,180 per family
Metal tier Silver

Visit Copay

Primary care visit No charge after deductible
Specialist visit $80 copay after deductible
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $50 copay after deductible
Emergency room 50% after deductible
Ambulance 50% after deductible
Hospital stay (facility) 50% after deductible
Hospital stay (physician) 50% after deductible
Outpatient procedure (facility) 50% after deductible
Outpatient procedure (physician) 50% after deductible
Physical rehabilitation $80 copay after deductible

Maternitowny and Pregnancy

Labor, delivery, hospital stay 50% after deductible

Pharmacy, Drugs, and Medication

Generic $15 copay after deductible
Brand $65 copay after deductible
Non-preferred Brand 50% after deductible
Specialty 50% after deductible

Lab Tests and Diagnostic Procedures

X-rays 50% after deductible
Imaging (CT/PET/MRI) 50% after deductible
Blood work 50% after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services 50% after deductible
Psychiatric hospital stay 50% after deductible

Health Plan Provider Information