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

Regular out-of-network services are only available through the Access Plan and Access HDHP. IYC Health Plan & High Deductible Health Plan offer out-of-network services only for emergency or urgent care. With the exception of WEA Trust East, WEA Trust West - Chippewa Valley, WEA Trust West - Mayo Clinic, and SMP. 
 

Access Plan

Access HDHP

Annual Medical Deductible

Individual / Family

Counts toward out-of-pocket limit (OOPL)

$500 / $1,000

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

After an individual within a family plan meets the $500 deductible, benefits apply as described below

$2,000 / $4,000

Must be met before coverage begins

Families: Must meet full family deductible

Combined medical and prescription drugs

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

100% until deductible is met

After deductible: You pay 30% up to OOPL

100% until deductible is met

After deductible: You pay 30% 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

100% until deductible is met

After deductible: You pay 30% up to OOPL

100% until deductible is met

After deductible: You pay 30% up to OOPL

Annual Medical Coinsurance

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

100% until deductible is met

After deductible: You pay 30% up to OOPL

100% until deductible is met

After deductible: You pay 30% up to OOPL

Preventive Services

See healthcare.gov/preventive-care-benefits

You pay deductible, copays and/or coinsurance

You pay deductible, copays and/or coinsurance

Transplants

100% until deductible is met

After deductible: You pay 30% up to OOPL

100% until deductible is met

After deductible: You pay 30% 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

100% until deductible is met

After deductible: You pay 30% up to OOPL

100% until deductible is met

After deductible: You pay 30% 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 in-network OOPL

In-network deductible and coinsurance may apply to services beyond the copay, up to OOPL

100% until deductible is met

After in-network deductible: $75 copay per visit

Copay counts toward in-network OOPL

In-network deductible and coinsurance may apply to services beyond the copay, up to OOPL

Medical Out-of-Pocket Limit (OOPL)

Individual / Family

$2,000 / $4,000

Does not apply to prescription drugs

$3,800 / $7,600

Combined medical and prescription drugs

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