Empire HMO 2250X Silver NS - DS by Empire
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Plan Information
- Plan Name
- Empire HMO 2250X Silver NS - DS
- Insurance Company
- Empire
In Network Benefits
- Office Co-pay
- 25% after deductible
- Specialist Co-pay
- $50 and 25% after deductible
- Hospital Co-pay
- 25% after deductible
- Emergency Room
- $200 and 25% after deductible
- Referrals Needed
- Yes
- Rx: Generic/Brand/High Brand
- $10/$30/40% after deductible
- In-Network Deductible (single/family)
- $2,250/$6,750
- In-Network Co-Insurance
- 0%
- Max Out of Pocket (single/family)
- $7,150/$14,300
Out Of Network Benefits
- Co-Insurance
- N/A
- Out of Pocket Max (single/family)
- N/A
Other Benefits
- Vision/Dental
- Pediatric Vision and Dental
- Renewal Date
- 01/01/2018
- HSA Eligible
- No
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