Exclusive provider organization (EPO)

When you enroll in the exclusive provider organization (EPO), you must use the plan’s national network of physicians, hospitals, and other healthcare providers to receive benefits; the EPO does not cover care received from out-of-network providers except for emergency services.

To better understand the coverage provided under the EPO, it’s important to know these key terms.

Deductible

The deductible is a specified annual dollar amount you must pay for covered medical services before the plan begins to pay benefits.

  • EPO deductibles are flat amounts, as shown on the Key Provisions chart
  • If you enroll any family members, you are responsible for two medical deductibles, one for yourself and one for all your family members combined. 
  • You can reduce your deductibles by completing Call to Health, a well-being initiative that focuses on the four dimensions of wholeness: spiritual, health, financial, and vocational.

Copay 

A copay is a flat dollar amount that you pay upfront for certain services when using network providers.

  • Except for preventive care, you pay a copay for each network office visit (in-person or virtual): $40 for primary and behavioral health care visits, $60 for visits to a specialist or when seeking care at an urgent care center, and $10 when using the telemedicine benefit
  • There are different copay requirements for certain other covered services, such as X-rays and laboratory tests, as shown on the Key Provisions chart
  • Copays do not count toward the plan deductible. 
  • There is a $25 copay for the vision exam benefift.
  • There are separate copay amounts for prescription drugs. Read more details.

Coinsurance

Coinsurance (previously referred to as a copayment) is the percentage of the cost for covered services that you pay after you pay the deductible: 

  • Your coinsurance for network medical services is 20 percent. 
  • The EPO does not cover out-of-network care or non-formulary prescription drugs.

Total maximum out-of-pocket

The total maximum out-of-pocket is the most you will pay in a year in the form of deductibles, copays, and coinsurance. If your covered out-of-pocket expenses reach the total maximum out-of-pocket amount, the plan will pay 100 percent of allowable costs for the rest of the year.

  • The EPO individual and family total maximum out-of-pocket amounts are shown on the Key Provisions chart.
  • Expenses that count toward the EPO total maximum out-of-pocket include your deductibles, office visit copays, coinsurance, and prescription drug copays.

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