This plan has a lower deductible and exclusively covers you for in-network doctors and facilities. Except in the case of an emergency, you’ll pay the full price for any out-of-network care.
|2020 EPO 500 PLAN HIGHLIGHTS|
|Provider Network||Extensive national network of contracted providers.|
|Primary Care Physician (PCP) to manage care||Not required|
|Referrals needed to see a specialist||Not required|
|Calendar Year Deductible||$500 per individual/$1,000 per family1|
|Health Savings Account (HSA)||No|
|Coinsurance (You Pay) After Meeting Deductible||20%|
|Calendar Year Out-of-Pocket Maximum||$2,000 per individual/$4,000 per family|
|Preventive Care||Covered in full (calendar year deductible waived)|
|Office Visit (You Pay)||$30 copay|
|Hospitalization||$500 copay2, then you pay 20%|
Network pharmacy: specified preventive drugs—100% covered3; generic—$10 copay3; brand formulary—$25 copay3; brand non-formulary—$40 copay3
|Pharmacy Mail Services
(up to 90-day supply)
Network pharmacy: specified preventive drugs—100% covered3; generic—$20 copay3; brand formulary—$50 copay3; brand non-formulary—$80 copay3
- The family deductible must be met before any person receives benefits.
- After calendar year deductible.
- Calendar year deductible waived.
- As specified in drug list.