IHC Silver EPO HSA Local Value $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
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $2,500 per person $2,500 per person |
| Out-of-pocket max | $7,500 per person $15,000 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) | first 5 day(s) $500 per day after deductible copay |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | 30% after deductible |
| Outpatient procedure (physician) | 30% after deductible |
| Physical rehabilitation | $75 copay after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | first 5 day(s) $500 per day after deductible copay |
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 copay after deductible |
| Imaging (CT/PET/MRI) | $100 copay after deductible |
| Blood work | No charge after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $75 copay after deductible |
| Psychiatric hospital stay | first 5 day(s) $500 per day after deductible copay |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/JCyMYG7oP6iPzzHrjqjUb6A8.pdf |
