Select $4,100 HDHP – EPO
Network type: EPO
Coverage tier: Silver
Primary care visit: $25 copay after deductible
Specialist visit: $75 copay after deductible
Urgent care visit: $75 copay after deductible
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $4,100 per person $4,100 per person |
| Out-of-pocket max | $7,050 per person $14,100 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $25 copay after deductible |
| Specialist visit | $75 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay after deductible |
| Emergency room | $450 copay after deductible |
| Ambulance | No charge after deductible |
| Hospital stay (facility) | $250 copay per Day after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | No charge after deductible |
| Outpatient procedure (physician) | No charge after deductible |
| Physical rehabilitation | $25 copay after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | No charge after deductible |
Pharmacy, Drugs, and Medication
| Generic | $5 copay after deductible |
| Brand | $60 copay after deductible |
| Non-preferred Brand | $120 copay after deductible |
| Specialty | 40% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | No charge after deductible |
| Imaging (CT/PET/MRI) | $250 copay after deductible |
| Blood work | No charge after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $25 copay after deductible |
| Psychiatric hospital stay | $250 copay per Day after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://www.securityhealth.org/IFPSelect_4100_01.pdf |
| Drug and medication plan formulary | https://www.securityhealth.org/4tierformulary |
| Search doctor list | http://www.securityhealth.org/selectproviders |
