Platinum IND POS Plus, Platinum, NS, OON, POS, Dep25, Family Vision, Family Dental, WP – POS
Network type: POS
Coverage tier: Platinum
Primary care visit: $10 copay
Specialist visit: $30 copay
Urgent care visit: $40 copay
Description
Health Care Plan Details
| Network type | POS |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $6,500 per person $13,000 per family |
| Metal tier | Platinum |
Visit Copay
| Primary care visit | $10 copay |
| Specialist visit | $30 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $40 copay |
| Emergency room | $300 copay |
| Ambulance | $300 copay |
| Hospital stay (facility) | $500 copay per Stay |
| Hospital stay (physician) | $30 copay |
| Outpatient procedure (facility) | $100 copay |
| Outpatient procedure (physician) | $100 copay |
| Physical rehabilitation | $10 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $530 copay |
Pharmacy, Drugs, and Medication
| Generic | $5 copay |
| Brand | $30 copay |
| Non-preferred Brand | 50% coinsurance |
| Specialty | No data available |
Lab Tests and Diagnostic Procedures
| X-rays | $30 copay |
| Imaging (CT/PET/MRI) | $30 copay |
| Blood work | $30 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $10 copay |
| Psychiatric hospital stay | $500 copay per Stay |
Health Plan Provider Information
| Health Plan Benefits | https://shop.highmark.com/sales/#!/sbcs/wny |
