Copays/coinsurance

Network providers

A “copay” is a fixed dollar amount you pay in lieu of a deductible and coinsurance at the time you receive medical services. When you see a network provider, copays apply to:

Office visits for non-preventive care under the HealthPlus and Health+Savings PPO Options

Note: If you use either the Westlake or Cherry Point Clinics, you will pay a reduced office visit copay.
Note: Under the Health+Savings PPO Option only, you must satisfy the applicable individual or family deductible first before the office visit copay will apply for these services. (The individual deductible applies if you have You Only coverage. The family deductible applies if you have You + Spouse, You + Child(ren) or You + Family coverage.)

The office visit copay includes:
  • The doctor office visit.
  • Diagnostic laboratory tests or X-rays performed in a doctor's office and billed as part of the visit.
  • Injections administered in a doctor's office as part of the visit (including allergy injections).
The office visit copay does not apply to:
  • Office visits if a surgical procedure as defined by Aetna is performed as part of the visit (for example, if a mole is removed or a broken bone is set during the office visit).
  • Prenatal maternity-related office visits (except for the first office visit to confirm the pregnancy). These visits are included in the delivery charge. However, post-natal maternity services are covered at 80% after the deductible.
  • Routine and diagnostic laboratory tests or X-rays performed:
    • In a doctor's office, but not at the time of the visit.
    • In a facility other than the doctor's office.
    • By an entity other than the doctor's office.
(Ask your doctor whether the lab facilities he/she uses are in the network.)
  • Chiropractic visits.
Emergency room facility charges Under the HealthPlus and Standard PPO Options, both network and out-of-network emergency room facility charges are covered at 80% after a copay, with no deductible.

Under the Health+Savings PPO Option, both network and out-of-network emergency room facility charges are covered at 80% after a copay, after the deductible.
Urgent care facility charges under the HealthPlus and Health+Savings PPO Options Under the HealthPlus PPO Option, network urgent care facility charges are covered at 100% after a copay, with no deductible.

Under the Health+Savings PPO Option, network urgent care facility charges are covered at 100% after a copay, and after the deductible is met.

When you use a network provider, eligible preventive care expenses are covered at 100% with no copay and no deductible. See Preventive care for details.

Most other covered services received from network providers (including non-preventive care office visits and urgent care facility charges under the Standard PPO Option) are paid at 80% of the contracted rate after you meet the individual or family plan year deductible, and you pay the remaining portion of the charges (the coinsurance).

Out-of-network providers

When you see an out-of-network provider for a covered expense, you typically pay a larger share of the cost. Most covered services received from out-of-network providers are paid at 60% of recognized charges after you meet the individual or family plan year deductible, and you pay the remaining portion of the charges (the coinsurance). You are responsible for paying any charges above the recognized charge limits.

Note: Eligible claims incurred in an emergency room facility will be covered at the applicable in-network benefit level.

You are also responsible for filing claim forms when you see out-of-network providers. (See How to file a claim.)

 

Publication date: April 2019

 

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