EPO Buy-up Snapshot
Covered Services | Plan Participant Responsibility | Special Comments |
Deductible, per plan year | $250 per participant with a | |
Maximum Out-of-Pocket. per plan year | $4,500 per participant with a $11,000 per family maximum | |
General Percentage Payment Rule | 20% after deductible | |
Office Visit - Primary Care | $25 co-payment, deductible waived | |
Office Visit - Specialist | $35 co-payment, deductible waived | |
Urgent Care Center | $35 co-payment, deductible waived | |
Teladoc | $0 copayment first two (2) consultations per plan year, then $35 per consultation, deductible waived | Through December 31, 2022 General Heath Teladoc visits are $0 copay |
Emergency Room | $250 co-payment, deductible and 20% coinsurance |
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Inpatient Hospital | 20% after deductible | Pre-certification required |
Ambulance | 20% coinsurance, deductible waived | Includes air ambulance. |
Single Diagnostic Test including Lab or X-Ray under $500 in allowable charges | $25 copayment - primary physician office | |
Single Diagnostic Test including Lab or X-Ray over $500 in allowable changes | 20% after deductible | Precertification required for any single diagnostic test over $1,000 in billed charges |
Please see the Summary Plan Description for the full Schedule of Benefits, Exclusions and Precertification Requirements |