Summary of Coverage
Coverage Details |
EPO PLANNS-EEH-SYSTEM |
EPO PLANCIGNA NETWORK |
|---|---|---|
Annual Deductible |
$700/person $1,400/family |
$1,600/person $3,200/family |
Annual Out-of-Pocket Maximum |
$4,500/person $9,000/family |
$9,000/person $18,000/family |
Coinsurance |
You pay 10% |
You pay 40% |
Employer HSA Funding |
No |
No |
Service Costs |
EPO PLANNS-EEH-SYSTEM |
EPO PLANCIGNA NETWORK |
|---|---|---|
Well Child Exam |
No cost |
No cost |
Routine Adult Physical Exam |
No cost |
No cost |
Primary Care Office Visit |
$25 copay |
You pay 40% |
Specialist Office Visit |
$40 copay |
You pay 40% |
Hospital Inpatient/Outpatient |
You pay 10% |
You pay 40% |
Urgent Care |
$40 copay |
$50 copay |
Emergency Department |
$250 copay |
$250 copay |
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