In-Network Medical Costs, Deductibles, and Out-of-Pocket Maximums
The Copays Shown Are Your Maximum Cost
Important! These in-network copay amounts are maximum amounts — if the service costs less than the copay, then you pay the lesser amount.
See "
Covered Service Categories" for a detailed description of the types of services that fall into each category below. This table highlights costs for in-network services. Out-of-network coverage is available for Options 1 and 2.
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Plan Option 1
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Plan Option 2
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TACC1:
<$100K
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TACC:
$100K+
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TACC:
<$100K
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TACC:
$100K+
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General Plan Information
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Network
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Aetna or Cigna
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Aetna or Cigna
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Out-Of-Network Coverage
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Yes
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Yes
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Primary Care Provider Selection Required
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No
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No
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Specialist Referral Required
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No
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No
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(a) Routine, Urgent, and Emergent Care
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Preventive Care
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$0
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Primary Care Office Visit (PCP, Pediatrician, OB/GYN)
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$15
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Telehealth
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Behavioral/Mental Health Office or Virtual Visits2 with psychologist/therapist or Psychiatrist
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|
Specialist Office Visit
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$50
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$75
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$75
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$100
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Physical , Speech , Occupational Therapy3
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$25
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$25
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$35
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$35
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Chiropractic Visit
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$50
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$50
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$50
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$50
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Basic Labs
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$20
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$20
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$35
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$35
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|
Urgent Care
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$50
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$75
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$75
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$100
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Ambulance
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$250
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$250
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$250
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$250
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Emergency Room
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$300
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$500
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$600
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$800
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(b) Medical Deductible for Other Medical Care Services Below
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|
Employee Only Coverage4
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$250
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$750
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$850
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$1,750
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Employee + Spouse/Domestic Partner or EE + Child(ren)
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$400
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$1,400
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$1,600
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$2,800
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Employee + Family (EE + Spouse/DP + Child(ren))
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$700
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$1,800
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$2,300
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$4,000
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(c) Other Medical Care
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Inpatient Hospital Admission
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If medical deductible (b) is not met, member pays 100% of costs. If medical deductible (b) is met, member pays 20% of costs.
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Outpatient Procedure / Surgery
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Advanced Imaging (CT/MRI)
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Standard Radiology
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Durable Medical Equipment
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(d) Out of Pocket Maximum (your "safety net," the most you will pay in a year medical services; includes what you spend in a + b + c)
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Employee Only Coverage4
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$1,250
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$2,000
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$2,800
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$4,000
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Employee + Spouse/Domestic Partner or EE + Child(ren)
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$2,500
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$3,400
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$4,700
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$5,900
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Employee + Family (EE + Spouse/DP + Child(ren))
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$3,500
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$5,100
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$6,600
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$8,400
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2 Certain mental health / substance use services, including but not limited to Inpatient partial hospitalization, transcranial magnetic stimulation (TMS), electroconvulsive therapy, and Intensive-out-patient (IOP) will be subject to 20% coinsurance, please contact your healthcare company to determine whether a deductible will apply.
3 See "
Covered Service Categories" for limits. For those individuals with a mental health diagnosis, the cost share for these services will be subject to 20% coinsurance (no deductible) rather than the copayment amounts noted in this chart.
4 Also serves as the per person amount for other coverage levels.
