The table below lists what you will pay for common services received out-of-network in the Access Plan. Your Certificate of Coverage (ET-2180) and Access Plan Schedule of Benefits detail all of your benefits.
The Access Plan and Access HDHP use the nationwide First Health provider network. In Southern Wisconsin, members also have access to Dean Health Plan providers. Visit the 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 Combined medical and prescription drugs Must be met before coverage begins Families: Must meet full family deductible before benefits apply as described below |
Annual Medical Coinsurance Applies to medical services except for emergency room copayments | After deductible: You pay 30% up to OOPL | 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 in-network 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 |
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 |
| 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 |