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:
- $35 for a Primary Care Physician (a PCP) or an in-store health clinic;
- $50 when you visit a Specialist;
- $35 for Psychological Counseling for a PCP and $50 for a Specialist visit; and
- $75 for Hospital Emergency Room visits, but this copay will be waived if the individual is admitted.
Other medical treatment is subject to a $750 deductible
(but no more than $1500 per family) during the calendar
year. Thereafter, such expenses will be coinsured with you
paying 40% 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 40% of the cost.
When you are hospitalized at an In-Network hospital you will
pay a copay of $500 and then 40% of the remaining 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 $7,500 per individual in
medical expenses (but no more than $15,000 per family) and
$7,500 per individual in behavioral health expenses (but no
more than $15,000 per family).
Prescription drugs are subject to the
copay which is applicable to the type
of drug indicated in the Core Plan
Chart. All brand drugs are first subject
to the $500 deductible per individual
each calendar year. 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.
Click here
for more information on generic drug substitution.
