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 | Nationwide except HI, EPO HP-Network in select locations nationwide |
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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