Exclusive provider organization (EPO)

To better understand the coverage provided under the EPO, it’s important to know these key terms.

Deductible

The deductible is a specified annual dollar amount you must pay for covered medical services before the plan begins to pay benefits.

• EPO deductibles are flat amounts, as shown on the Key Provisions chart. 
• If you enroll any family members, you are responsible for two medical deductibles, one for yourself and one for all your family members combined. 
• You can reduce your deductible(s) by completing Call to Health, a well-being initiative that focuses on the four dimensions of wholeness: spiritual, health, financial, and vocational.

Copay 

A copay is a flat dollar amount that you pay upfront for certain services when using network providers.

• Except for preventive care, you pay a copay for each network office visit (in-person or virtual): $40 for primary and behavioral health care visits, $60 for visits to a specialist or when seeking care at an urgent care center, and $10 when using the telemedicine benefit. 
• There are different copay requirements for certain other covered services, such as X-rays and laboratory tests, as shown on the Key Provisions chart. 
• Copays do not count toward the plan deductible. 
• There is a $25 copay for the vision exam benefit.
• There are separate copay amounts for prescription drugs. Read more details.

Coinsurance

Coinsurance is the percentage of the cost for covered services that you pay after you pay the deductible: 

• Your coinsurance for network medical services is 20 percent. 
• The EPO does not cover out-of-network care (except for emergency services) or non-formulary prescription drugs.

Total maximum out-of-pocket

The total maximum out-of-pocket is the most you will pay in a year in the form of deductibles, copays, and coinsurance. If your covered out-of-pocket expenses reach the total maximum out-of-pocket amount, the plan will pay 100 percent of allowable costs for the rest of the year.

• The EPO individual and family total maximum out-of-pocket amounts are shown on the Key Provisions chart.
• Expenses that count toward the EPO total maximum out-of-pocket include your deductible(s), office visit copays, coinsurance, and prescription drug copays (excluding certain non-essential specialty pharmacy drugs).