The table below lists costs for common services for each It's Your Choice plan design option. Your Certificate of Coverage details all of your benefits.

Regular out-of-network services are only available through the Local Access HDHP. The Local HDHP offers out-of-network services only for emergency or urgent care.

 

In-Network Services

Local HDHP & Local Access HDHP

Out-Of-Network Services

Local Access HDHP

Annual Deductible

Includes medical and prescription drugs.

$1,500 individual / $3,000 family

The deductible must be met before coverage begins; for family coverage, the full family deductible must be met

The deductible includes prescription drugs and applies to OOPL

$2,000 individual / $4,000 family

The deductible must be met before coverage begins; for family coverage, the full family deductible must be met

The deductible includes prescription drugs and applies to OOPL

Primary Care Physician (PCP) Office Visit Copayment

Includes:

  • Internist 
  • General Physician 
  • Family Practitioner 
  • Pediatrician 
  • Gynecologist / Obstetrician 
  • Nurse Practitioner 
  • Physician Assistant 
  • Chiropractor 
  • Physical / Occupational / Speech Therapy in an office visit setting

You pay the full allowed amount of an office visit until deductible is met

After deductible: You pay $15 copay per office visit up to OOPL

Coinsurance will apply to additional services such as lab work, X-rays, etc.

You pay the full allowed amount of an office visit until deductible is met

After deductible: You pay 30% coinsurance up to OOPL

Specialty Office Visit Copayment

Includes:

  • Specialty Providers 
  • Urgent Care 
  • Vision Exam in an office visit setting.

You pay the full allowed amount of an office visit until deductible is met

After deductible: You pay $25 copay per office visit up to OOPL

Coinsurance will apply to additional services such as lab work, X-rays, etc.

You pay the full allowed amount of an office visit until deductible is met

After deductible: You pay 30% coinsurance up to OOPL

Annual Medical Coinsurance

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL

Applies to medical services except for office visit or emergency room copays and preventive services*

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL

Applies to medical services except for emergency room copays

Annual Out-of-Pocket Limit (OOPL)
Includes medical and prescription drugs

$2,500 individual / $5,000 family

For family coverage, you must meet the full family OOPL before your plan pays 100%

$3,800 individual / $7,600 family

For family coverage, you must meet the full family OOPL before your plan pays 100%

Routine, preventive services as required by federal law

Plan pays 100%, not subject to deductible
For details, visit healthcare.gov

Subject to the deductible and coinsurance

Illness/injury related services beyond the office visit copayment (if applicable)

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL

Applies to medical services except for office visit or emergency room copays

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL

Applies to medical services except for emergency room copays

Emergency Room Copayment 

(Waived if admitted as an inpatient directly from the emergency room or for observation for 24 hours or longer.)

You pay the full allowed amount of services until deductible is met

After deductible: You pay $75 copay per visit, then coinsurance applies to services beyond the copay up to OOPL

You pay the full allowed amount of services until deductible is met

After deductible: You pay $75 copay per visit, then in-network deductible and coinsurance applies to services beyond the copay up to OOPL

Transplants

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL

Mental Health/Alcohol & Drug Abuse

Outpatient services: after deductible, you pay $15 copay for primary care office visits. Additional services such as lab
work, assessments, etc., are subject to coinsurance

Inpatient and covered transitional services: after deductible plan pays 90%, you pay 10% coinsurance up to OOPL

All services apply  to the annual OOPL

Outpatient, inpatient and covered transitional services: after deductible plan pays 70%, you pay 30% coinsurance up to OOPL

Hearing aid (per ear)

You pay the full allowed amount of services until deductible is met

After deductible: Every three years:

Adults, you pay 20% coinsurance up to plan paid $1,000 (not to OOPL); dependents younger than age 18, plan pays 90%, you pay 10% coinsurance up to OOPL

You pay the full allowed amount
of services until deductible is met

Every three Years:

After deductible:For dependents younger than age 18, plan pays 70%, you pay 30% coinsurance up to OOPL

Cochlear Implants

You pay the full allowed amount of services until deductible is met

Adults, after deductible, plan pays 80%, you pay 20% coinsurance up to OOPL for device, surgery for implantation, follow-up sessions;

For hospital charge for surgery:

Adults, after deductible plan pays 90%, you pay 10% coinsurance up to OOPL

Dependents under age 18, after deductible, plan pays 90%, you pay 10% coinsurance up to OOPL for all services

You pay the full allowed amount
of services until deductible is met

Dependents under age 18, after deductible plan pays 70%, you pay 30% coinsurance up  to OOPL for device, surgery, follow-up sessions

Skilled Nursing Facility
(non-custodial care)

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL, 120 days per benefit period

You pay the full allowed amount
of services until deductible is met

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL, 120 days per benefit period

Home Health
(non-custodial)

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL, 50 visits per year

Plan may approve an additional 50 visits

You pay the full allowed amount
of services until deductible is met

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL, 50 visits per plan year

Plan may approve an additional 50 visits

Physical/Speech/Occupational Therapy

You pay the full allowed amount of services until deductible is met

After deductible: You pay $15 copay for office visits. Additional services such as lab
work, X-rays, etc. are subject to coinsurance up to OOPL

50 combined visits per year

Plan may approve an additional 50 visits per therapy type per year

You pay the full allowed amount
of services until deductible is met

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL

50 combined visits per plan year

Plan may approve an additional 50 visits per therapy type per year

Durable Medical Equipment

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL

Precertification for hospitalizations, high-tech radiology and low back surgery

Varies by plan

See plan descriptions and contact your plan

Contact WEA Trust

Referrals

In-network–varies by plan. See plan descriptions and contact your plan

For the Local HDHP, a referral is required for any benefits to be covered out-of-network

Not required

Oral Surgery

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 90%, you pay 10% coinsurance up to OOPL

You pay the full allowed amount of services until deductible is met

After deductible: Plan pays 70%, you pay 30% coinsurance up to OOPL

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