Out-of-Network Medical Costs, Deductibles, and Out-of-Pocket Maximums
| |
Plan Option 1
|
Plan Option 2
|
| |
TACC:
<$100k
|
TACC:
$100k+
|
TACC:
<$100k
|
TACC:
$100k+
|
|
Medical Deductible
|
|
Employee-Only Coverage1
|
$2,750
|
$4,750
|
|
Employee + Spouse/Domestic Partner or Employee + Child(ren)
|
$4,125
|
$7,125
|
|
Employee + Family (Employee + Spouse/Domestic Partner + Child(ren))
|
$5,500
|
$9,500
|
|
Cost Share
|
|
Preventive Care
|
50% after deductible
|
50% after deductible
|
|
Primary Care Office Visit (PCP, Pediatrician, OB/GYN)
|
50% after deductible
|
50% after deductible
|
|
Telehealth
|
Not covered
|
Not covered
|
|
Mental Health Office Visits
|
50% after deductible
|
50% after deductible
|
|
Specialist Office Visit
|
50% after deductible
|
50% after deductible
|
|
Physical/Occupational/Speech Therapy
|
50% after deductible
|
50% after deductible
|
|
Chiropractic Visit
|
50% after deductible
|
50% after deductible
|
|
Basic Labs
|
50% after deductible
|
50% after deductible
|
|
Urgent Care
|
50% after deductible
|
50% after deductible
|
|
Inpatient Hospital Admission
|
50% after deductible
|
50% after deductible
|
|
Outpatient Procedure/Surgery
|
50% after deductible
|
50% after deductible
|
|
Standard Radiology
|
50% after deductible
|
50% after deductible
|
|
Advanced Imaging (MRI, CT)
|
50% after deductible
|
50% after deductible
|
|
Durable Medical Equipment (DME)/Prosthetics/Appliances
|
50% after deductible
|
50% after deductible
|
|
Ambulance
|
$250 copay (no deductible)
|
$250 copay (no deductible)
|
|
Emergency Room
|
$300 copay (no deductible)
|
$500 copay (no deductible)
|
$600 copay (no deductible)
|
$800 copay (no deductible)
|
|
Medical Out-of-Pocket Maximum
|
|
Employee-Only Coverage1
|
$8,750
|
$10,750
|
|
Employee + Spouse/Domestic Partner or Employee + Child(ren)
|
$12,125
|
$15,125
|
|
Employee + Family (Employee + Spouse/Domestic Partner + Child(ren))
|
$17,500
|
$21,500
|
1 Also serves as the per person amount for other coverage levels
