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.
Urgent Care
2024 Plan Information
| Option A | Option B | Option C |
|---|---|---|
| Note | ||
The figures in the chart below reflect what the Plan pays, with the exception of deductibles and out-of-pocket maximums, which employees pay. | ||
| Most other services, including inpatient and outpatient hospital and specialist visits | ||
In-Network: 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: 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: 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: 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: 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: Prior proof of medical necessity may apply for certain services. Check with your health plan administrator to verify coverage and if preauthorization is required. |
| Individual Annual Deductible | ||
In-Network: Out-of-Network: | In-Network: Out-of-Network: | In-Network: Out-of-Network: |
| Family Deductible | ||
In-Network: Out-of-Network: | In-Network: Out-of-Network: | In-Network: Out-of-Network: |
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.