IND Destination 65, Silver, NS, INN, POS, Dep25, Pediatric Dental – POS

Network type: POS
Coverage tier: Silver
Primary care visit: No charge after deductible
Specialist visit: $40 copay after deductible
Urgent care visit: $60 copay after deductible

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Description

Health Care Plan Details

Network type POS
Deductible $2,500 per person $2,500 per person
Out-of-pocket max $9,450 per person $18,900 per family
Metal tier Silver

Visit Copay

Primary care visit No charge after deductible
Specialist visit $40 copay after deductible
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $60 copay after deductible
Emergency room $300 copay after deductible
Ambulance $300 copay after deductible
Hospital stay (facility) $750 copay per Stay after deductible
Hospital stay (physician) $40 copay after deductible
Outpatient procedure (facility) $400 copay after deductible
Outpatient procedure (physician) $400 copay after deductible
Physical rehabilitation No charge after deductible

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay $790 copay after deductible

Pharmacy, Drugs, and Medication

Generic $15 copay
Brand $50 copay
Non-preferred Brand 50% coinsurance
Specialty No data available

Lab Tests and Diagnostic Procedures

X-rays $125 copay after deductible
Imaging (CT/PET/MRI) $225 copay after deductible
Blood work No charge after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services No charge after deductible
Psychiatric hospital stay $750 copay per Stay after deductible

Health Plan Provider Information

Health Plan Benefits https://shop.highmark.com/sales/#!/sbcs/neny