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 (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. Except for counseling visits, behavioral health services are coinsured with you paying 30% of the cost.
When you are hospitalized in an In-Network hospital, you will pay a copay of $350 and then 30% of the remaining cost. If you are hospitalized an additional time during the year or if any other family member is hospitalized, a second $350 copay will not apply for that year.
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.
Visits to the emergency room of an In-Network hospital for routine (non-emergency) medical treatment are not covered.
