IND Destination 65, Gold, NS, INN, POS, Dep25, Pediatric Dental – POS
Network type: POS
Coverage tier: Gold
Primary care visit: No charge
Specialist visit: $35 copay after deductible
Urgent care visit: $60 copay
Description
Health Care Plan Details
| Network type | POS |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | No charge |
| Specialist visit | $35 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $60 copay |
| Emergency room | $300 copay |
| Ambulance | $300 copay |
| Hospital stay (facility) | $750 copay per Stay |
| Hospital stay (physician) | $35 copay |
| Outpatient procedure (facility) | $400 copay |
| Outpatient procedure (physician) | $400 copay |
| Physical rehabilitation | No charge |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $785 copay |
Pharmacy, Drugs, and Medication
| Generic | $5 copay |
| Brand | $50 copay |
| Non-preferred Brand | 50% coinsurance |
| Specialty | No data available |
Lab Tests and Diagnostic Procedures
| X-rays | $100 copay after deductible |
| Imaging (CT/PET/MRI) | $225 copay |
| Blood work | No charge |
Mental and Psychiatric Health Care
| Mental Health outpatient services | No charge |
| Psychiatric hospital stay | $750 copay per Stay |
Health Plan Provider Information
| Health Plan Benefits | https://shop.highmark.com/sales/#!/sbcs/neny |
