Innovation Health – Gold 3 HMO + Pediatric Dental – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $15 copay
Specialist visit: $35 copay
Urgent care visit: $25 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | See brochure See brochure |
| Out-of-pocket max | N/A per person N/A per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $15 copay |
| Specialist visit | $35 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $25 copay |
| Emergency room | 50% after deductible |
| Ambulance | 50% after deductible |
| Hospital stay (facility) | 50% after deductible |
| Hospital stay (physician) | 50% after deductible |
| Outpatient procedure (facility) | 40% after deductible |
| Outpatient procedure (physician) | 40% after deductible |
| Physical rehabilitation | $35 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 50% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $15 per script copay |
| Brand | $40 per script copay |
| Non-preferred Brand | 40% after deductible |
| Specialty | 50% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $35 copay |
| Imaging (CT/PET/MRI) | 40% after deductible |
| Blood work | $20 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $15 copay |
| Psychiatric hospital stay | 50% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/jdnQkxYaFfxcgq83MC7B866q.pdf |
| Drug and medication plan formulary | https://client.formularynavigator.com/Search.aspx?siteCode=6179884039 |
