Empire HMO 5250X Silver NS by Empire
Scroll down to the Summary of Benefits PDF
Plan Information
- Plan Name
- Empire HMO 5250X Silver NS
- Insurance Company
- Empire
In Network Benefits
- Office Co-pay
- $35
- Specialist Co-pay
- 25% after deductible
- Hospital Co-pay
- 25% after deductible
- Emergency Room
- 25% after deductible
- Referrals Needed
- Yes
- Rx: Generic/Brand/High Brand
- $5/$40/35% after deductible
- In-Network Deductible (single/family)
- $5,250/$10,500
- In-Network Co-Insurance
- 0%
- Max Out of Pocket (single/family)
- $6,500/$13,000
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
Check if you qualify for this Health Insurance plan:
Or give us a call, our expert agents will be happy to assist you. It's toll-free!