With the EPO HP-Network Plan, if you live in a high-performance network location, you can enroll in the EPO HP-Network Plan. Otherwise you can enroll in the EPO Network Plan.
EPO Plan | |||||||||||||||||||||||||||||||||||
Where Available | |||||||||||||||||||||||||||||||||||
Annual Deductible - Associate - Family | Embedded $1,500 $4,500 Annual Out-of-Pocket Max - Associate - Family Embedded $5,000 $15,000 IN-NETWORK - YOU PAY Preventive Care $02 Teladoc Telemedicine Visit - Medical - Mental Health $20 per visit $20 per visit Office Visit - PCP - Specialist $20 copay3 $40 copay3 Urgent Care $40 copay3 Emergency Room $200 copay + 30%2 Diagnostic Testing PCP office: $20 copay3 Specialist office: $40 copay3 Outpatient X-Ray and Lab PCP office: $20 copay3 Specialist office: $40 copay3 Hospitalization - Inpatient Semi-Private Room - Inpatient Physician 30%2 30%2 Outpatient Treatment (Physical, Occupational & Speech Therapy) $40 copay3 Mental Health/Substance Abuse - Inpatient - Outpatient 30%2 $20 copay3 (Outpatient psychotherapy) Pharmacy Retail 30-day supply - Annual Deductible Applies - Pharmacy Out-of-Pocket Max No Combined with medical $0 copay 20% (min $30, max $90) 30% (min $60, max $120) Pharmacy Retail/Mail Order 90-day supply $0 copay 20% (min $90, max $270) 30% (min $180, max $360) | ||||||||||||||||||||||||||||||||||
1) Coinsurance you pay after you meet the annual deductible unless otherwise noted.
2) Annual deductible waived.
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