IND POS 200, Gold, NS, OON, POS, Dep29, Pediatric Dental – POS
Network type: POS
Coverage tier: Gold
Primary care visit: $20 copay after deductible
Specialist visit: $40 copay after deductible
Urgent care visit: $50 copay after deductible
Description
Health Care Plan Details
| Network type | POS |
| Deductible | $1,700 per person $1,700 per person |
| Out-of-pocket max | $5,700 per person $11,400 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $20 copay after deductible |
| Specialist visit | $40 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 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) | $150 copay after deductible |
| Outpatient procedure (physician) | $150 copay after deductible |
| Physical rehabilitation | $20 copay after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $790 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $5 copay after deductible |
| Brand | $40 copay after deductible |
| Non-preferred Brand | 50% coinsurance after deductible |
| Specialty | No data available |
Lab Tests and Diagnostic Procedures
| X-rays | $40 copay after deductible |
| Imaging (CT/PET/MRI) | $40 copay after deductible |
| Blood work | $40 copay after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $20 copay after deductible |
| Psychiatric hospital stay | $750 copay per Stay after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://shop.highmark.com/sales/#!/sbcs/wny |
