Standard Gold Child Only Gold ST OON IHC Network Marketplace DP FP – POS
Network type: POS
Coverage tier: Gold
Primary care visit: $25 copay after deductible
Specialist visit: $40 copay after deductible
Urgent care visit: $60 copay after deductible
Description
Health Care Plan Details
| Network type | POS |
| Deductible | N/A N/A |
| Out-of-pocket max | N/A per person N/A per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $25 copay after deductible |
| Specialist visit | $40 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $60 copay after deductible |
| Emergency room | $150 copay after deductible |
| Ambulance | $150 copay after deductible |
| Hospital stay (facility) | $1,000 copay after deductible |
| Hospital stay (physician) | $100 copay after deductible |
| Outpatient procedure (facility) | $100 copay after deductible |
| Outpatient procedure (physician) | $100 copay after deductible |
| Physical rehabilitation | $30 copay after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $1,100 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | $35 copay |
| Non-preferred Brand | $70 copay |
Lab Tests and Diagnostic Procedures
| X-rays | $40 copay after deductible |
| Imaging (CT/PET/MRI) | $40 copay after deductible |
| Blood work | $40 copay after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $25 copay after deductible |
| Psychiatric hospital stay | $1,000 copay after deductible |