A quick reference guide to your benefits and costs
Note: The chart below shows what the member pays at the time of care. See employee medical plan premium contributions for your share of premium costs for each plan.
This is a summary only. Important details — such as limitations, exclusions, exceptions, and other qualifiers — may not be included. For detailed information, call the plan or see their website for specific benefits, benefits when traveling overseas, provider information, and plan booklets. If any information on the website conflicts with plan documents, plan documents prevail.
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Definitions
Calendar year deductible: The amount you must pay for medical services before the plan will provide benefits.
Annual out-of-pocket maximum: The amount you must pay during the calendar year before the plan will pay 100% of covered charges. Some expenses do not apply toward the maximum; see the plan’s evidence of coverage booklet.
Copayments: Shown in dollars; represents the amount you pay after the deductible (if any) has been met.
Coinsurance: Shown as a percentage; represents the percentage of the allowable amount you pay after the deductible (if any) has been met.
Allowable amount: The dollar amount considered payment-in-full for services provided by the health plan carrier’s network of healthcare providers. (Out-of-network providers may bill members for amounts in excess of the allowable amount.)