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Copayments ("Copays") You Pay for Covered Services
No PCP or Referrals
Remember: You are not required to select or assign a Primary Care Physician (PCP) and you do not need referrals to see a specialist in the Simplified Medical Plan.
In the Simplified Medical Plan, you pay a fixed copay per service you receive as detailed in the chart below, rather than deductibles and coinsurance. However, if you choose to go out-of-network, there is a deductible that you must meet prior to the Plan sharing in the costs of your healthcare; once you reach the deductible, the copays in the chart below will apply.



The Copays Shown Are Your Maximum Cost
Important! These copay amounts are maximum amounts — if the service or drug 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.
Medical Service
In-Network
Out-of-Network
Total Annual Cash Compensation (TACC)1: <$60,000
Total Annual Cash Compensation (TACC)1: $60,000+
All TACC1 levels
Option 1
Option 2
Option 1
Option 2
Options 1 & 2
Preventive care
Free
Free
Free
Free
$60
Primary care office visit (PCP, Pediatrician, OB/GYN)
$15
$15
$15
$15
$60
Medical Virtual doctor visit
$15
$15
$15
$15
Not applicable
Behavioral/Mental Health Virtual Visits2 services delivered through Teladoc (Aetna) and MDLive (Cigna)
         
Psychologist/Therapist
$15
$15
$15
$15
Not applicable
Psychiatrist
$75
$110
$75
$110
Not applicable
Outpatient therapy for mental health2, chemical, alcohol dependence
$15
$15
$15
$15
$60
Lab
$20
$35
$20
$35
$60
Physical therapy, speech therapy, occupational therapy, and cognitive rehabilitation therapy service3
$25
$35
$25
$35
$80
Chiropractic visit
$50
$50
$50
$50
$100
Standard radiology
$50
$75
$75
$75
$200
Urgent care visit
$50
$75
$100
$100
$200
Specialist office visit2
$75
$110
$100
$110
$350
Outpatient procedure/surgery
$300
$600
$500
$800
$1,500
Durable medical equipment (DME)
$100
$100
$100
$100
$300
Advanced imaging (CT/MRI) — per service
$250
$350
$250
$350
$1,000
Ambulance
$250
$250
$250
$250
$250
Emergency room (ER) visit4
$500
$750
$800
$900
Same as In-Network
Hospitalization (inpatient admission)
$1,000/day
$1,250/day
$1,000/day
$1,250/day
$3,000/day
1 Total Annual Cash Compensation (see "Total Annual Cash Compensation").
2 Psychologists are classified in outpatient therapy and psychiatrists are classified as specialists.
3 See "Covered Service Categories" for limits.
4 Non-emergency care will cost $100 more for Option 1 and $150 more for Option 2.