EPO: deductibles, copays, copayments, and out-of-pocket maximums

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

​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: $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 are separate copay amounts for the vision exam benefit and prescription drugs. See Key Provisions EPO for details.

Copayment

A copayment is the percentage of the plan allowance for covered services that you pay after meeting the deductible: 

  • Your copayment for network services is 20 percent. 
  • The EPO does not cover out-of-network care.

Combined maximum out-of-pocket 

The combined maximum out-of-pocket is a specified annual dollar amount you pay for covered medical and prescription services, after which the plan pays 100 percent of allowable costs for the rest of the year. 

The EPO combined maximum out-of-pocket amounts are shown on the Key Provisions chart

Expenses that count toward the EPO combined maximum out-of-pocket include your deductibles, office visit copays, copayments, and prescription drug copays.