The table below lists what you will pay for common services received out-of-network. Your Certificate of Coverage (ET-2180) and Access Plan Schedule of Benefits details all of your benefits.
The Access Plan and Access HDHP use the First Health provider network. Visit the First Health Locate a Provider page to confirm your provider is in-network. If you choose to seek care from an out-of-network provider, you will be responsible for paying higher out-of-pocket costs.
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 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 |
Annual Medical Coinsurance Applies to medical services except for emergency room copayments |
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 |
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% |
Primary Care Office Visit Additional services such as lab work, X-rays, etc., count toward the deductible and coinsurance Includes:
|
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:
|
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 |
You pay deductible and/or coinsurance |
You pay deductible and/or coinsurance |
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 |
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 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 |