Non-Standard Low Gold: HNE Thrive Gold 2000 – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $10 copay
Specialist visit: $30 copay
Urgent care visit: $30 copay
Description
Health Care Plan Details
Network type | HMO |
Deductible | $2,000 per person $2,000 per person |
Out-of-pocket max | $8,200 per person $16,400 per family |
Metal tier | Gold |
Visit Copay
Primary care visit | $10 copay |
Specialist visit | $30 copay |
Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
Urgent care | $30 copay |
Emergency room | $500 copay after deductible |
Ambulance | $100 copay after deductible |
Hospital stay (facility) | $1,000 copay after deductible |
Hospital stay (physician) | No charge after deductible |
Outpatient procedure (facility) | $1,000 copay after deductible |
Outpatient procedure (physician) | No charge after deductible |
Physical rehabilitation | $30 copay after deductible |
Maternitowny and Pregnancy
Labor, delivery, hospital stay | $1,000 copay after deductible |
Pharmacy, Drugs, and Medication
Generic | $10 copay |
Brand | $50 copay |
Non-preferred Brand | $150 copay |
Specialty | $200 copay |
Lab Tests and Diagnostic Procedures
X-rays | $50 copay after deductible |
Imaging (CT/PET/MRI) | $500 copay after deductible |
Blood work | $25 copay |
Mental and Psychiatric Health Care
Mental Health outpatient services | $10 copay |
Psychiatric hospital stay | $1,000 copay after deductible |