Effective October 1, 2019
By choosing from among our health plan’s network of 40,000 high-quality, In-Network healthcare providers, our members can keep out-of-pocket costs low.
Example #1 Using an in-network provider
- Member with chronic condition
- 20 office visits
- Member pays $20 copay for each visit
- Total: $400
Example #2 Using an out of network provider
- Member with chronic condition
- 20 office visits
- Out-of-Network provider charges $250 per visit
- Member pays in full for the first four visits, reaching $1000 Annual Individual Deductible
- Member then pays coinsurance of 30% of provider charges, $75 per visit.
- Member reaches the Annual Individual Out-of-Pocket Maximum of $2000 during the 18th visit
- Member pays $0 for last two visits*
- Total: $2000
Example #3 Using an in-network provider
- Member with chronic condition, as above, pays $400
- Family member #2 has pregnancy-related claims of $12,800
- Family member #2 pays $20 copayment for the first doctor’s visit confirming pregnancy
- Family Member #2 pays $0 for prenatal, postnatal, and delivery costs
- Family member #3 has X-ray claim of $500
- Family member #3 pays nothing for X-ray
- Total: $420
Example #4 Using an out of network provider
- Member with chronic condition, as above, pays a total of $2000
- Family Member #2 has pregnancy-related claims of $12,800Family Member #2 pays the first $1000 towards meeting the $1000 Annual Individual Deductible.
- Family Member #2 then pays 30% of the next $3,500 in claims, reaching the $2,000
- Annual Individual Out-of-Pocket Maximum.
- Family Member #2 pays $0 for remainder of claims. *
- Family Member #3 has X-ray claim of $500
- Family Member #3 pays $500 towards meeting the $5000 Annual Family Out-of-Pocket
- Maximum
- Total: $4,500
By using in-network providers, members and their families can save up to 90% of out-of-pocket costs.
*The Plan will pay the Out-of-Network provider the Allowed Amount; Participant may be balance billed for higher amounts by the Out-of-Network provider. Balance billing is when the Out-of-Network Provider bills you for the difference between what the Plan pays and the amount of the provider’s actual charges.
