Active Employees & non-Medicare eligible Retirees
| Plan Specifics | You Pay (for PCP/ Plan-Approved Benefits) | You Pay (for Self-Referred Major Medical Benefits – after your deductible) |
|---|---|---|
| Calendar-year deductible | $250 (member), $750 (family) | |
| Calendar-year Out-of-Pocket maximum for PCP/ Plan-Approved and Self-Referred combined | $5,000 (member), $10,000 (family) | |
| Benefit | You Pay (for PCP/ Plan-Approved Benefits) | You Pay (for Self-Referred Major Medical Benefits – after your deductible) |
| Preventive care, routine physicals, GYN, well child, routine hearing and vision exams, family planning | Nothing, no deductible | |
| Office visits (sick care/ non-preventive) | $15 per visit, no deductible | 20% co-insurance after deductible1 |
| Office visits (specialists) | $25 per visit, no deductible | 20% co-insurance after deductible1 |
| Emergency room | $75 per visit after deductible (copayment waived if admitted or for an observation stay) | |
| Inpatient hospital care | Nothing after deductible | 20% co-insurance after deductible1 |
1. In addition to your deductible and 20% co-insurance, you may be responsible for any balance of charges above the allowed charge.
NOTE: You also have the option to seek covered services from a covered provider who is not a network provider. (These health care providers are often called "non-network providers.") In this case, you usually receive the lowest benefit level under this health plan (your Self-Referred Benefits).
