EPO Plan Snapshot
Covered Services | Plan Participant Responsibility | Special Comments |
Deductible, per plan year | $500 per participant with a $1,500 maximum per family | |
Maximum Out-of-Pocket, per plan year | $6,000 per participant with a $14,300 maximum per family | |
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 co-payment first two consultations per plan year then $35 co-payment per consultation, deductible waived | Through December 31, 2022 General Health Teladoc Visits are covered with $0 copay |
Emergency Room | $250 co-payment, deductible and 20% coinsurance | Co-payment is waived if admitted to the hospital on an emergency basis. Non-emergency treatment in the ER is not covered. |
Inpatient Hospital | 20% after deductible | Pre-certification is required |
Ambulance | 20% coinsurance, deductible waived | Includes air ambulance. |
Single Diagnotic Test including lab and x-ray under $500 in allowable charges | $25 copayment - primary physician office | |
Single Diagnostic Test including lab and x-ray over $500 allowable charges | 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 | ||