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HSA Plan

Network

20% coinsurance after deductible

Non-Network

Network Benefit

PPO 750 Plan

Network

$250 copayment plus 20% coinsurance after deductible
Medicare: 20% coinsurance after deductible

Non-Network

Network Benefit

PPO 1250 Plan

Network

$250 copayment plus 20% coinsurance after deductible
Medicare: 20% coinsurance after deductible

Non-Network

Network Benefit

Emergency Room Copayment

Members visiting an emergency room (ER) may pay a $250 copayment. The copayment is waived if the member is admitted to the hospital or the services are considered by the medical plan to be a "true emergency." Even if the copayment is waived, the member will still have to pay any deductible or coinsurance owed for the ER services.

Copayments apply to the out-of-pocket maximum, but not the deductible.


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