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.
