CopayBook.indd

HRA Choice Plus Plan 604 / 05U Coverage Period: 03/01/2016 – 02/28/2017 Summary of Benefits and Coverage: What This Plan Covers & What it Costs Coverage for: Employee & Family Plan Type: HMO  Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.  Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan’s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven’t met your deductible .  The amount the plan pays for covered services is based on the allowed amount . If a non-network provider charges more than the allowed Common Medical Event Services You May Need Your Cost If You Use a Network Provider Your Cost If You Use a Non-Network Provider Limitations & Exceptions If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $35 copay per visit 30% co-ins after ded. Virtual visits (Telehealth) – $5 copay per visit by a designated virtual network provider. No virtual coverage out-of-network. If you receive services in addition to office visit, additional copays, deductibles, or co-ins may apply. Specialist visit $50 copay per visit 30% co-ins after ded. If you receive services in addition to office visit, additional copays, deductibles, or co-ins may apply. Other practitioner office visit $25 copay per visit 30% co-ins after ded. Cost share applies to manipulative (chiropractic) services only and is limited to 24 visits per Preventive care / screening / immunization No Charge Not Covered* If you have a test Diagnostic test (x-ray, blood work) No Charge 30% co-ins after ded.

amount , you may have to pay the difference. For example, if a non-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing .)  This plan may encourage you to use network providers by charging you lower deductibles , copayments and coinsurance amounts. calendar year. Pre-authorization is required non- network or benefit reduces to 50% of eligible expenses. Includes preventive health services specified in the health care reform law. *Certain services are covered when using a non-network provider. Pre-authorization is required non-network for sleep studies or benefit reduces to 50% of eligible expenses.

benefit reduces to 50% of eligible expenses.

Imaging (CT / PET scans, MRIs) 0% co-ins after ded. 30% co-ins after ded. Pre- authorization is required non-network or