Gold EPO 500 20 7350 by Empire
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Plan Information
- Plan Name
- Gold EPO 500 20 7350
- Insurance Company
- Empire
In Network Benefits
- Office Co-pay
- $25
- Specialist Co-pay
- $50
- Hospital Co-pay
- 20% after deductible
- Emergency Room
- $400
- Referrals Needed
- No
- Rx: Generic/Brand/High Brand
- $10/$50/$75
- In-Network Deductible (single/family)
- $500/$1,000
- In-Network Co-Insurance
- 20%
- Max Out of Pocket (single/family)
- $7,350/$14,700
Out Of Network Benefits
- Deductible (single/family)
- N/A
- Co-Insurance
- N/A
- Out of Pocket Max (single/family)
- N/A
Other Benefits
- Vision/Dental
- Pediatric Vision and Dental; Adult Vision Only
- Renewal Date
- Annual
- HSA Eligible
- No
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