Silver 1010 – EPO
Network type: EPO
Coverage tier: Silver
Primary care visit: $50 copay
Specialist visit: $75 copay
Urgent care visit: $55 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $50 copay |
| Specialist visit | $75 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $55 copay |
| Emergency room | 50% coinsurance |
| Ambulance | 50% coinsurance |
| Hospital stay (facility) | 50% coinsurance |
| Hospital stay (physician) | 50% coinsurance |
| Outpatient procedure (facility) | $500 copay |
| Outpatient procedure (physician) | $150 copay |
| Physical rehabilitation | 50% coinsurance |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 50% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | $20 copay |
| Brand | 50% after deductible |
| Non-preferred Brand | 50% after deductible |
| Specialty | Share |
Lab Tests and Diagnostic Procedures
| X-rays | $75 copay |
| Imaging (CT/PET/MRI) | $100 copay |
| Blood work | $22 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $50 copay |
| Psychiatric hospital stay | 50% coinsurance |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/G7Jf7ApFfiYU8sYVS1Y8nmQZ.pdf |
