A comprehensive plan with a $35 copay for doctor office visits. Or choose the $25 copay optional benefit for two doctor visits.
Plan Benefits Chart
|In-Network Benefit Highlights||Copay SelectSM1|
(maximum 2 per family, per calendar year)
|You pay: $1,0002, $1,5002, $2,500, $3,500, $5,000, $7,500, $10,000, or $12,500|
|Coinsurance (% of covered expenses after deductible)||You pay: 0% 20% 30%|
|Coinsurance Out-of-Pocket Maximum (per person, per calendar year, after deductible)||$0, $3,000, $5,000, or 10,000|
|Physician Care Benefits (Illness & Injury)|
|Office Visit, History, and Exam (primary care or specialist)||$35 copay — no deductible|
|Primary Care Physician/Specialist Referrals Required||No|
|Prescription Drug Benefits|
|If you purchase name-brand when generic is available, you pay your generic copay plus the additional cost above the generic price.||Name Brand and Generic3
Tier 1 drugs — $15 copay, no deductible.
Tier 2-4 drugs — combined $500 deductible per person, per calendar year, then:
Tier 2 drugs — $35 copay.
Tier 3 drugs — $65 copay.
Tier 4 drugs — you pay 25% coinsurance.
|Wellness/Preventive Care Benefits (no waiting period, not subject to deductible, coinsurance, or copayments)|
|Preventive care||No charge — 100% covered in network. See page 16 of brochure for details.|
|Outpatient Expense Benefits|
|X-ray and Lab (performed in the doctor’s office or a network facility)||You pay: chosen coinsurance after deductible|
|Facility/Hospital for Outpatient Surgery||You pay: chosen coinsurance after deductible|
|Surgeon, Assistant Surgeon, and Facility Fees||You pay: chosen coinsurance after deductible|
|Hemodialysis, Radiation, Chemotherapy, Organ Transplant Drugs, and CAT Scans, MRIs||You pay: chosen coinsurance after deductible|
|Emergency Room Fees — Illness||You pay: chosen coinsurance after deductible
(additional $100 ER deductible if not admitted)
|Emergency Room Fees — Injury||You pay: chosen coinsurance after deductible|
|Spine and Back Disorders||You pay: chosen coinsurance after deductible (limited benefit)|
|Other Outpatient Expenses||You pay: chosen coinsurance after deductible|
|Inpatient Expense Benefits|
|Room and Board, Intensive Care Unit, Operating Room, Recovery Room, Prescription
Drugs, Physician Visit, and Professional Fees of Doctors, Surgeons, Nurses
|You pay: chosen coinsurance after deductible|
|Other Inpatient Services||You pay: chosen coinsurance after deductible|
Optional Benefits Available1
Optional benefits are available to add for more protection or more savings.
Benefits to Reduce Premium
- 2-Dr. Office Visit Copay
- 4-Dr. Office Visit Copay
- $15 Generic RX Only
- RX Discount Card Only
Benefits to Enhance Plan
- $25 Office Visit Copay
- RX $200 Deductible
- Accidental Death
- Mental Disorders/Substance Abuse
- Supplemental Accident
- Term Life