Copayments and Benefit Percentages
The plan's coinsurance (percentage coverage) does not begin until after the annual deductible has been met. All copayments apply before the annual deductible. The copayments and percentages of reimbursement are listed under the Summary of NAP Benefits.
Eligible Expenses will be reimbursed based on negotiated rates for network providers and Customary and Reasonable Charges for non-network providers, after any copayments and after meeting the annual deductible. If your non-network provider bills an amount above the Customary and Reasonable Charges (Eligible Expenses), you will be responsible for paying this difference along with your coinsurance. Network providers have agreed not to charge you more than the negotiated rate, so you will not be responsible for any amount in excess of the negotiated rate for Covered Health Services when you use a network provider.
Outpatient Hospital Services
The NAP provides coverage for outpatient hospital services including outpatient surgery, radiation therapy, chemotherapy and hemodialysis. For outpatient hospital emergency room visits, you must pay a $35 copayment for each visit. Your $35 copayment will not be applied to your annual deductible; however, it will count toward your annual out-of-pocket maximum (see "Plan Maximums"). Please note that any labwork and/or X-rays you receive are covered separately after the deductible at 90% in-network and 70% out-of-network.
Physician Office Visit Copayment
Benefits are provided for primary care physician office visits for illness or disease after you pay a $10 copayment per in-network visit and meet your annual deductible. The in-network copayment for a specialist visit is $20. No referral from your primary care physician will be required in order for you to see your specialist. The office visit copayment applies first, then the annual deductible. If you go to a non-network provider, the NAP pays 70% of Customary and Reasonable (C&R) Charges after your deductible (see "How Benefits Are Determined").