Nurse with Protective Mask

COPAY plan example

Plan Deductible: $1,500
Plan Coinsurance: 80%/20%
Plan Out-of-Pocket Maximum: $7,000
Plan Copays: $35
Plan Rx Copays: $15/$25/$45

Services that have a Copay

Using the plan example above, you pay the $35 copay.

Annual Preventive
Regular Doctor
Specialist Doctor
Hearing Exam
Outpatient Mental Health
Chiropractic Care
Acupuncture
Outpatient Physical Therapy
Outpatient Occupational Therapy Outpatient Rehabilitation
Prescriptions

Services Subject to the Deductible

Using the plan example above, you pay the full cost of these services until you have paid your $1,500 deductible, then you pay 20% of the total cost until you have paid $7,000 for the year. Then the plan will pay 100% for covered services.

Ambulance 
Emergency Room
Inpatient Mental Health
Inpatient Rehabilitation
Inpatient Physical Therapy
Orthotics / Durable Medical Equipment
Hospice
Organ Transplants
Surgery 
Hospital Visits

Prescriptions

Using the plan example above, you pay the corresponding copay: $15 for Preferred Generic prescriptions, $25 for Preferred Brand name prescriptions, $45 for Non-Preferred Generic and Brand name prescriptions

Preferred Generic
Preferred Brand Name
Non-Preferred Generic
Non-Preferred Brand Name

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