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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 (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 $1,500 per family) during the calendar year. Thereafter, such expenses will be coinsured with you paying 40% of the cost.

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.