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

Combined medical & prescription drugs:

$1,600 / $3,200

Must be met before coverage begins

Families: Must meet full family deductible before benefits apply as described below

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

Medical Out-of-Pocket Limit (OOPL)

Individual / Family

$1,250 / $2,500

Does not apply to prescription drugs

$2,500 / $5,000

Combined medical & prescription drugs

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

Preventive Services

See healthcare.gov/preventive-care-benefits

Plan pays 100%

Plan pays 100%

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 is met

After deductible, $75 copay per visit

Copay counts toward OOPL

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

Mental Health/Alcohol and Drug Abuse

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

Outpatient services: $15 copay per visit up to OOPL

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

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

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

Transplants

 After deductible, you pay 10% up to OOPL After deductible, you pay 10% up to OOPL

 *For additional Access Plan out-of-pocket amounts, see the Out-Of-Network Access Plan Health Services page.