The initial $ 4,900 of coinsurance and co-payments is applied to both the in and out-of-network coinsurance/co-payment maximum. After the initial $4,900 has been applied, only the coinsurance amount for services rendered by non-participating providers will be applied to the additional $3,000 out-of-network coinsurance/co-payment maximum. Once the annual coinsurance/co-payment maximum is met, the Plan pays 100% of the allowable charge for covered medical expenses and prescription drugs for the remainder of that calendar year, except as otherwise specified.
The Plan will never pay 100% for those expenses that do not apply toward satisfying the coinsurance/co-payment maximum.
Coinsurance Once a participant has met the calendar year deductible, the Plan pays a portion of the allowable charge for covered medical expense. The participant pays the remainder in the form of coinsurance.
Any fees charged by a non-participating provider that are above the allowable charge are not part of the coinsurance amount. The Plan will not pay any portion of these charges.
Helpful Tip: Participating providers agree not to charge any amount above the Plan’s allowable charge.
Do These Expenses Count Towards The Coinsurance/Co-Payment Maximum?
The coinsurance paid for hospital inpatient services
The coinsurance paid for other covered expenses
Coinsurance and other expenses for treatment of substance abuse (alcohol and/or drug) and mental health conditions
The private room co-payment
The emergency room co-payment
Prescription drug co-payments
The calendar year deductible
Expenses in excess of the allowable charge
Expenses in excess of Plan maximum limits
Utilization review penalties
Services not covered by the Plan including all those found in the Medical Limitations and Exclusions section
Generic drug differential amounts
Services not considered medically necessary