Doctor Visits

2020 and 2021 Plan Year Information

Option AOption BOption C
Note

The figures in the chart below reflect what the Plan pays, with the exception of deductibles and out-of-pocket maximums.

Most other services, including inpatient and outpatient hospital and specialist visits

In-Network:
80% after annual deductible

Prior proof of medical necessity may apply for certain services. Check with your health plan administrator to verify coverage and if preauthorization is required.

Out-of-Network:
60% of eligible expenses after annual deductible

Prior proof of medical necessity may apply for certain services. Check with your health plan administrator to verify coverage and if preauthorization is required.

In-Network:
80% after annual deductible

Prior proof of medical necessity may apply for certain services. Check with your health plan administrator to verify coverage and if preauthorization is required.

Out-of-Network:
60% of eligible expenses after annual deductible

Prior proof of medical necessity may apply for certain services. Check with your health plan administrator to verify coverage and if preauthorization is required.

In-Network:
80% after annual deductible

Prior proof of medical necessity may apply for certain services. Check with your health plan administrator to verify coverage and if preauthorization is required.

Out-of-Network:
60% of eligible expenses after annual deductible

Prior proof of medical necessity may apply for certain services. Check with your health plan administrator to verify coverage and if preauthorization is required.

Diagnostic and Preventive Care

In-Network:
100% (no annual deductible)

Out-of-Network:
100% up to a maximum of $250 (no annual deductible) then 60% of eligible expenses (no annual deductible)

In-Network:
100% (no annual deductible)

Out-of-Network:
100% up to a maximum of $250 (no annual deductible) then 60% of eligible expenses (no annual deductible)

In-Network:
100% (no annual deductible)

Out-of-Network:
100% up to a maximum of $250 (no annual deductible) then 60% of eligible expenses (no annual deductible)

Individual Deductible

In-Network:
$600

Out-of-Network:
$1,200

In-Network:
$1,200

Out-of-Network:
$2,400

In-Network:
$2,300 (includes prescription drugs)

Out-of-Network:
$4,600 (includes prescription drugs)

Family Deductible

In-Network:
$1,250

Out-of-Network:
$2,500

In-Network:
$2,500

Out-of-Network:
$5,000

In-Network:
$4,600 (includes prescription drugs)

Out-of-Network:
$9,200 (includes prescription drugs)

Non-Preventive Services

For non-preventive health care services, including office visits, coinsurance will apply after you have met your annual deductible. That means you will pay a percentage of the cost of services (coinsurance) rather than a flat fee (copay). The amount you pay in coinsurance plus the annual deductible during the year will not exceed your annual out-of-pocket maximum.

Out-of-Network Reimbursements

Out-of-network reimbursements are based on eligible expenses as determined by the Plan administrator. You are responsible for any payments required to the provider in excess of the reasonable and customary amount.

Amounts paid to out-of-network providers count toward the in-network and out-of-network annual deductible. The amount you pay toward your annual deductible is included in your out-of-pocket maximum.