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 coinsurance and copays are listed in the Summary of CAP 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 CAP 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 deductible; however, it will count toward your annual out-of-pocket maximum. Please note that any lab work and/or X-rays you receive are covered separately after the deductible at 90%.
Please refer to "Emergency Care" for more information on emergency care.
Physician Office Visit Copayment
Benefits are provided for primary care physician office visits for illness or disease after you pay a $10 copayment per visit. The copayment for a specialist visit is $20. The office visit copayment does not apply to the annual deductible; however, it will count toward your annual out-of-pocket maximum.