In-Network Plan Benefits
In-Network benefits are subject to a copay when you visit
a physician for service. The copay amounts are as follows:
- $25 for a Primary Care Physician (a PCP) or an in-store health clinic;
- $40 when you visit a Specialist;
- $15 for Psychological Counseling; and
- $50 for Hospital Emergency Room visits, but this copay will be waived if the individual is admitted.
Other medical treatment is subject to a $400 deductible
(but no more than $700 per family) during the calendar
year. Thereafter, such expenses will be coinsured with you
paying 30% of the cost.
Behavioral health services are not subject to the Plan
deductibles. Except for counseling visits, behavioral health
services are coinsured with you paying 30% of the cost.
Visits to the emergency room of an In-Network hospital
for routine (non-emergency) medical treatment are not
covered. Your total out-of-pocket cost for deductible and
coinsurance expenses is limited to no more than $5,000
per individual in medical expenses and $5,000 per individual
in behavioral health expenses. There is no out-of pocket
limit for the family.
Prescription drugs are subject to the
copay which is applicable to the type
of drug indicated in the Basic Plan
Chart. If you have a prescription for
a brand drug for which there is a
generic equivalent drug, the generic
will be issued instead unless the
prescribing physician has indicated
that substitution may not occur. In
that case the cost of the prescription
first will be subject to the $500
deductible per family each calendar
year. Click here for
more information on generic
drug substitution.
