Silver PPO 2700 30 5000 HSA by Empire
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Plan Information
- Plan Name
- Silver PPO 2700 30 5000 HSA
- Insurance Company
- Empire
In Network Benefits
- Office Co-pay
- 30% after deductible
- Specialist Co-pay
- 30% after deductible
- Hospital Co-pay
- 30% after deductible
- Emergency Room
- 30% after deductible
- Referrals Needed
- No
- Rx: Generic/Brand/High Brand
- $10/$50/$80
- In-Network Deductible (single/family)
- $2,700/$5,400
- In-Network Co-Insurance
- 30%
- Max Out of Pocket (single/family)
- $5,000/$10,000
Out Of Network Benefits
- Deductible (single/family)
- $5,400/$10,800
- Co-Insurance
- 50%
- Out of Pocket Max (single/family)
- $10,000/$20,000
Other Benefits
- Vision/Dental
- Pediatric Vision and Dental; Adult Vision Only
- Renewal Date
- Annual
- HSA Eligible
- Yes
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