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Nurse with Protective Mask

COPAY plan example

Deductible: $1,500
Coinsurance: 80%/20%

(plan pays 80%)
Out-of-Pocket Maximum: $7,000

(most individual every pays in plan year)
Office Visit Copay: $35
Rx Copays: $15 / $25 / $45

Office Visits
(flat copay)

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

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

Inpatient / Outpatient Services
(deductible / coinsurance)

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.

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

(flat copays)

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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