The table below lists costs for common services received in-network. Your Schedule of Benefits and Certificate of Coverage contain the details for 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: $1,650 / $3,300 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:
| $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:
| $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 | 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.