11 2023 | Benefits Guide Medical Savings Plan Tier 1 ECU Health Alliance/In-Network Tier 2 MedCost/In-Network Tier 3 Out-of-Network Preventive Covered at 100% Covered at 100% Plan pays 50%, you pay 50% Plan Coinsurance Ded., then 15% coins. Ded., then 25% coins. Ded., then 50% coins. PCP Visit Ded., then 5% coins. Ded., then 25% coins. Ded., then 50% coins. Specialty Visit Ded., then 10% coins. Ded., then 25% coins. Ded., then 50% coins. Behavioral Health Office Visit Ded., then 5% coins. Ded., then 5% coins. Ded., then 50% coins. ECU HealthNow Ded., then $0 Ded., then $0 Ded., then $0 Med Deductible (Single/Family) $2,000/$4,000 $2,500/$5,000 $6,000/$12,000 Med Max OOP (Single/Family) $6,000/$12,000 $6,750/$13,500 $12,500/$25,000 Rx Max OOP (Single/Family) Included with medical OOP max Included with medical OOP max Included with medical OOP max Combined OOP Max (Med + Rx) $6,000/$12,000 $6,750/$13,500 $12,500/$25,000 Emergency Room Ded., then 15% coins. Tier 1 ded., then 15% coins.* Tier 1 ded., then 15% coins.* Urgent Care Ded., then 15% coins. Ded., then 25% coins. Ded., then 50% coins. Inpatient/Outpatient Hospital Ded., then 15% coins. Ded., then 25% coins. Ded., then 50% coins. * For these services, you first pay the Tier 1 deductible, and then the coinsurance. Basic Plan Tier 1 ECU Health Alliance/In-Network Tier 2 MedCost/In-Network Tier 3 Out-of-Network Preventive Covered at 100% Covered at 100% Ded., then 50% coins. Plan Coinsurance Plan pays 85%, you pay 15% Plan pays 75%, you pay 25% Plan pays 50%, you pay 50% PCP Visit $10 copay $50 copay Ded., then 50% coins. Specialty Visit $25 copay $60 copay Ded., then 50% coins. Behavioral Health Office Visit $10 copay $10 copay Ded., then 50% coins. ECU HealthNow Covered at 100% Covered at 100% Covered at 100% Med Ded. (Single/Family) $1,200/$2,400 $1,500/$3,000 $4,500/$9,000 Med Max OOP (Single/Family) $4,000/$8,000 $5,000/$10,000 $10,000/$20,000 Rx Max OOP (Single/Family) $2,500/$5,000 $2,500/$5,000 $2,500/$5,000 OOP Max (Med + Rx) $6,500/$13,000 $7,500/$15,000 $12,500/$25,000 Emergency Room $250 copay + ded./ 15% coins. $250 copay + Tier 1 ded./ 15% coins.* $250 copay + Tier 1 ded./ 15% coins.* Urgent Care $50 copay $60 copay Ded., then 50% coins. In/Outpatient Hospital Ded., then 15% coins. Ded., then 25% coins. Ded., then 50% coins. * For these services, you first pay the Tier 1 deductible, and then the coinsurance.
