IHC Select Silver EPO HSA AmeriHealth Hospital Advantage $50/$75 – EPO

Network type: EPO
Coverage tier: Silver
Primary care visit: $50 copay after deductible
Specialist visit: $75 copay after deductible
Urgent care visit: $85 copay after deductible

SKU: 91762NJ0070101 Category:

Description

Health Care Plan Details

Network type EPO
Deductible See brochure See brochure
Out-of-pocket max N/A per person N/A per family
Metal tier Silver

Visit Copay

Primary care visit $50 copay after deductible
Specialist visit $75 copay after deductible
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $85 copay after deductible
Emergency room $100 copay after deductible
Ambulance 50% after deductible
Hospital stay (facility) 20% after deductible
Hospital stay (physician) 20% after deductible
Outpatient procedure (facility) 20% after deductible
Outpatient procedure (physician) 20% after deductible
Physical rehabilitation $75 copay after deductible

Maternitowny and Pregnancy

Labor, delivery, hospital stay 20% after deductible

Pharmacy, Drugs, and Medication

Generic $10 copay after deductible
Brand 50% 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 No charge after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services $75 copay after deductible
Psychiatric hospital stay 20% after deductible

Health Plan Provider Information

Health Plan Benefits https://d2ed110nmrd591.cloudfront.net/blobs/jRBsKkDx8qerjuA5afDvFmfB.pdf