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

- Specified Preventive Drugs2,3

- Generic

- Brand Preferred

- Brand Non-Preferred

100% covered2,3

$10 copay

20% (min $30, max $90)

30% (min $60, max $120)

Pharmacy Retail/Mail Order

90-day supply

- Specified Preventive Drugs2,3

- Generic

- Brand Preferred

- Brand Non-Preferred

100% covered2,3

$30 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.
3) As specified in essential drug list.