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HSA Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

PPO 750 Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

PPO 1250 Plan

Network

Primary Care/Mental Health:
$25 copayment
Specialist:
$40 copayment
Medicare: 20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

Telehealth services are covered for the diagnosis, consultation, or treatment of a member on the same basis that the service would be covered when it is delivered in person.

Telehealth site origination fees or costs for the provision of telehealth services are not covered.

See also: Teladoc®


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