OMNIA Gold – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: $10 copay
Specialist visit: $25 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $500 per person $500 per person |
| Out-of-pocket max | $7,000 per person $14,000 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $10 copay |
| Specialist visit | $25 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | $100 copay after deductible |
| Ambulance | No charge after deductible |
| Hospital stay (facility) | first 5 day(s) $500 per day then $0 copay after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | $200 copay after deductible |
| Outpatient procedure (physician) | No charge after deductible |
| Physical rehabilitation | $20 copay after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | first 5 day(s) $500 per day then $0 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $20 copay |
| Brand | 30% after deductible |
| Non-preferred Brand | 30% after deductible |
| Specialty | 30% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $20 copay |
| Imaging (CT/PET/MRI) | $20 copay after deductible |
| Blood work | $20 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $10 copay |
| Psychiatric hospital stay | first 5 day(s) $500 per day then $0 copay after deductible |
