Out of Pocket (Stop Loss)
Coverage Level: Individual
Service Type: Health Benefit Plan Coverage
Insurance Type Code: HM Health Maintenance Organization (HMO)
Time Period Qualifier: Calendar Year
Amount: $8,500.00
In Plan Network Indicator: Unknown
Deductible
Coverage Level: Individual
Service Type: Vision (Optometry)
https://luna.ema.md/ema/patient/InsuranceOverviewForm.action?pic1.0u85-w2bBh0R86_K9v71KolpMN1sZmZ0Lxolu1TW4qD3al-JJFDVNX81... 13/172/21/22, 10:26 AM Luna Dermatology: Patient Insurance
Insurance Type Code: HM Health Maintenance Organization (HMO)
Plan Coverage Description: Fidelis Care Silver
Amount: $0.00
Authorization/Certification Req'd: No
In Plan Network Indicator: no
Co-Payment
Coverage Level: Individual
Service Type: Vision (Optometry)
Insurance Type Code: HM Health Maintenance Organization (HMO)
Plan Coverage Description: Fidelis Care Silver
Amount: $0.00
Authorization/Certification Req'd: No
In Plan Network Indicator: Yes
Co-Insurance
Coverage Level: Individual
Service Type: Vision (Optometry)
Insurance Type Code: HM Health Maintenance Organization (HMO)
Plan Coverage Description: Fidelis Care Silver
Authorization/Certification Req'd: No
In Plan Network Indicator: Unknown