Silver Blue Priority EPO 2700-0%-4500 w HSA by Empire
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Plan Information
- Plan Name
- Silver Blue Priority EPO 2700-0%-4500 w HSA
- Insurance Company
- Empire
In Network Benefits
- Office Co-pay
- $25 then 0% after deductible
- Specialist Co-pay
- $50 then 0% after deductible
- Hospital Co-pay
- $500 then 0% after deductible
- Emergency Room
- $300 then 0% after deductible
- Referrals Needed
- No
- Rx: Generic/Brand/High Brand
- $10/$40/$80 after deductible
- In-Network Co-Insurance
- 0%
- Max Out of Pocket (single/family)
- $4,500/$9,000
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
- Yes
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