Standard Platinum ST OON IHC Network DP FP Dep 29 – POS
Network type: POS
Coverage tier: Platinum
Primary care visit: $15 copay
Specialist visit: $35 copay
Urgent care visit: $55 copay
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 | Platinum |
Visit Copay
| Primary care visit | $15 copay |
| Specialist visit | $35 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $55 copay |
| Emergency room | $100 copay |
| Ambulance | $100 copay |
| Hospital stay (facility) | $500 copay |
| Hospital stay (physician) | $100 copay |
| Outpatient procedure (facility) | $100 copay |
| Outpatient procedure (physician) | $100 copay |
| Physical rehabilitation | $25 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $500 copay |
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | $30 copay |
| Non-preferred Brand | $60 copay |
Lab Tests and Diagnostic Procedures
| X-rays | $35 copay |
| Imaging (CT/PET/MRI) | $35 copay |
| Blood work | $35 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $15 copay |
| Psychiatric hospital stay | $500 copay |