The table below lists costs for common services received in-network. Your Certificate of Coverage details all of your benefits.

 

IYC Health Plan & Access Plan

High Deductible Health Plan (HDHP) & Access HDHP

Annual Medical Deductible

Individual / Family

Counts toward out-of-pocket limit (OOPL)

$250 / $500

Medical deductible does not apply to office visit copays, preventive services or prescription drugs

After an individual within a family plan meets the $250 deductible, benefits apply as described below

$1,500 / $3,000

Must be met before coverage begins

Families: Must meet full family deductible

Primary Care Office Visit

Additional services such as lab work, X-rays, etc., count toward the deductible and coinsurance

Includes:

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

$15 copay per visit up to OOPL

Does not count toward deductible

You pay 100% until deductible is met

After deductible: $15 copay per visit up to OOPL

Specialty Office Visit

Additional services such as lab work, X-rays, etc., count toward the deductible and coinsurance

Includes:

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

$25 copay per visit up to OOPL

Does not count toward deductible

You pay 100% until deductible is met

After deductible: $25 copay per visit up to OOPL

Annual Medical Coinsurance

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

After deductible you pay 10% up to OOPL

After deductible you pay 10% up to OOPL

Preventive Services

See healthcare.gov/preventive-care-benefits

Plan pays 100%

Plan pays 100%

Transplants

After deductible you pay 10% up to OOPL

After deductible you pay 10% up to OOPL

Mental Health/Alcohol and Drug Abuse

Paid until OOPL is met

Additional services such as lab work, assessments, etc., are subject to deductible and coinsurance

Outpatient services: $15 copay per visit

Inpatient & covered transitional services: after deductible, you pay 10%

Outpatient services: after deductible: $15 copay per visit up to OOPL

Inpatient & covered transitional services: after deductible, you pay 10% up to OOPL

Emergency Room

Copay waived if admitted as an inpatient directly from the emergency room or for observation for 24 hours or longer.

$75 copay per visit

Copay counts toward OOPL

Deductible and coinsurance may apply to services beyond the copay, up to OOPL

You pay 100% until deductible met

After deductible: $75 copay per visit

Copay counts toward OOPL

Deductible and coinsurance may apply to services beyond the copay, up to OOPL

Medical Out-of-Pocket Limit (OOPL)

Individual / Family

$1,250 / $2,500
Does not apply to Rx

$2,500 / $5,000
Combined medical & Rx

Families: Must meet full family OOPL before your plan pays 100%

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