Major Medical Copay 3500
Plan Information
Major Medical insurance plan with copays for common services and opportunities for $0 care. Click the down arrow to learn more about this plan.
Network Type
PPO/Open
Tier 1 Preferred: Care Coordination
For Tier 1 preferred benefits with no out-of-pocket costs, contact our Care Coordination team before getting services. Our experts will locate high-quality, low-cost providers nearby. If you book an appointment with their recommended provider, your care is free. While Care Coordination strives to find Tier 1 providers, it's not always possible, so Tier 1 benefits aren't assured.
Tier 2: In Network
The PHCS Network for VDHPs grants you access to nearly a million providers nationwide, including select ancillary service providers for labs, home health, clinics, and more. Check out the user-friendly provider lookup at www.hstconnect.com/PHCS to easily find participating providers near you, access hospital quality scores, and compare out-of-pocket costs for providers.
Hospital Services
This plan pays hospitals and facilities based on a reference-based price, which is fair and objective. For Non-Participating Providers, you pay your copay or coinsurance plus any difference between the reimbursement level and the billed amount. Any excess charges aren't counted towards your deductible or out-of-pocket maximum. If you get a bill for these charges, call us for help.
Official Documents
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Deductible & Out-of-Pocket Limit
Tier 1 Preferred Network
Tier 2 Participating Providers
Tier 3 Non-Participating Providers
Individual Deductible
In Network Preferred
$0
In Network
$3,500
Out of Network
$3,500
The amount you could owe during a coverage period for covered health care services before the plan begins to pay.
Family Deductible
In Network Preferred
$0
In Network
$7,000
Out of Network
$7,000
If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.
Individual Out-of-Pocket Limit
In Network Preferred
$7,000
In Network
$7,000
Out of Network
$14,000
The most you could pay during a coverage period for your share of the costs of covered services. After you meet this limit the plan will usually pay 100% of the allowed amount. This limit helps you plan for health care costs. This limit never includes your premium, balance-billed charges, health care your plan doesn’t cover, and penalties for non-compliance with plan provisions.
Family Out-of-Pocket Limit
In Network Preferred
$14,000
In Network
$14,000
Out of Network
$28,000
If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.
In Network Preferred
In Network
Out of Network
There are dozens of preventive care services available for free with this plan, including check-ups, counseling, screenings, and immunizations. These services are government mandated. To learn more, scroll down to the Free Preventive Care section below.
Primary care visit
In Network Preferred
N/A
In Network
$25 copay
Out of Network
50% coinsurance
Primary care visits are appointments with your primary care provider to look at symptoms, sickness, or injuries.
This is different from preventive care visits - annual checkups or screenings are always free. The copay covers up to $500 per visit, and the deductible applies to costs over $500.
Specialist visit
In Network Preferred
Free
In Network
$45 copay (office visit) / 30% coinsurance (outpatient hospital)
Out of Network
50% coinsurance
A specialist is a medical professional who specializes in a condition or area of the body. For example, a dermatologist (skin), cardiologist (heart), neurologist (brain), or oncologist (cancer). The copay covers up to $500 per visit, and the deductible applies to costs over $500.
Referrals are not needed to see specialists.
Urgent Care
In Network Preferred
Free
In Network
$65 copay (office) / 30% coinsurance (hospital)
Out of Network
50% coinsurance (office) / N/A (outpatient hospital)
An urgent care center can be a convenient option if you have a non-life-threatening injury and your doctor is not available.
Urgent care is usually less expensive than going to the Emergency Room, and will usually have shorter wait times for non-life-threatening injuries.
Telemedicine 24/365
In Network Preferred
N/A
In Network
Free
Out of Network
N/A
Prescriptions
Prescription coverage is based on which category a drug falls into. To see how this plan categorizes prescriptions, browse its drug formulary.
Tier 1 Preferred Network
Tier 2 Participating Providers
Tier 3 Non-Participating Providers
Generic
In Network Preferred
N/A
In Network
$0 copay
Out of Network
Not covered, except in emergencies
A generic drug is identical to the brand name drug in form, safety, strength, quality and intended use. Although identical, generic drugs are substantially cheaper than their brand name counterparts. Deductible does not apply.
Preferred Brand
In Network Preferred
N/A
In Network
$35 copay
Out of Network
Not covered, except in emergencies
Brand drugs are more expensive than generic drugs. Not every brand drug has a generic equivalent.
Non-preferred Brand
In Network Preferred
N/A
In Network
$75 copay
Out of Network
Not covered, except in emergencies
Generally these are higher-cost drugs that have recently come on the market. In most cases, an alternative preferred drug is available.
In Network Preferred
In Network
Out of Network
X-rays
In Network Preferred
Free
In Network
$50 copay (independent lab) / 30% coinsurance (outpatient hospital)
Out of Network
50% coinsurance (ind. lab) / N/A (outpatient hospital)
This includes the use of X-rays to diagnose a condition. The copay covers up to $500 per visit, and the deductible applies to costs over $500.
Imaging (CT/PET/MRI)
In Network Preferred
Free
In Network
30% coinsurance
Out of Network
50% coinsurance
Imaging includes diagnostic services such as CT scans, PET scans, and MRIs.
There is a $500 penalty for failure to obtain prior authorization. If non-recommended providers/facilities are used on non-emergency services, a 25% benefit payment reduction penalty will apply.
Labs/Bloodwork
In Network Preferred
Free
In Network
$50 copay (independent lab) / 30% coinsurance (outpatient hospital)
Out of Network
50% coinsurance (ind. lab) / N/A (outpatient hospital)
Blood tests are often used to help diagnose a condition, or check levels such as cholesterol or blood sugar. The copay covers up to $500 per visit, and the deductible applies to costs over $500.
In Network Preferred
In Network
Out of Network
Emergency Room
In Network Preferred
N/A
In Network
30% coinsurance
Out of Network
N/A
This includes services to check for an emergency medical condition* and treatment to keep it from getting worse. These emergency services may be provided in any licensed hospital’s emergency room or another place that provides care for emergency medical conditions.
*An emergency medical condition is defined as an illness, injury, symptom (including severe pain), or condition severe enough to risk serious danger to your health if you didn't get medical attention right away.
There is a $1,000 penalty for non-emergency visits. Notification is required within 48 hours or as soon as reasonably possible, and coinsurance is waived if you are admitted as inpatient.
Ambulance
In Network Preferred
N/A
In Network
30% coinsurance
Out of Network
N/A
This covers emergency transportation and off-site treatment for emergency medical conditions* and may also cover non-emergency transportation between hospitals.
*An emergency medical condition is defined as an illness, injury, symptom (including severe pain), or condition severe enough to risk serious danger to your health if you didn't get medical attention right away.
Hospital stay (facility)
In Network Preferred
Free
In Network
30% coinsurance
Out of Network
N/A
This is the amount you’re responsible for when using the facilities and equipment at a hospital.
There is a $500 penalty for failure to obtain prior authorization. If non-recommended providers/facilities are used on non-emergency services, a 25% benefit payment reduction penalty will apply.
Hospital stay (physician)
In Network Preferred
Free
In Network
30% coinsurance
Out of Network
N/A
This is the amount you’re responsible for when receiving services provided by a physician, surgeon, medical doctor, or other specialists.
There is a $500 penalty for failure to obtain prior authorization. If non-recommended providers/facilities are used on non-emergency services, a 25% benefit payment reduction penalty will apply.
Outpatient procedure (facility)
In Network Preferred
Free
In Network
30% coinsurance
Out of Network
N/A
This is the amount you’re responsible for when using the equipment and facilities at a hospital.
Specifically, during a procedure that does not require overnight hospitalization.
There is a $500 penalty for failure to obtain prior authorization. If non-recommended providers/facilities are used on non-emergency services, a 25% benefit payment reduction penalty will apply.
Physical rehabilitation
In Network Preferred
Free
In Network
$45 copay
Out of Network
50% coinsurance
There is a $500 penalty for failure to obtain prior authorization. If non-recommended providers/facilities are used on non-emergency services, a 25% benefit payment reduction penalty will apply.
Rehabilitation & Habilitation have a combined limit of 30 days per plan year.
In Network Preferred
In Network
Out of Network
Outpatient Services
In Network Preferred
Free
In Network
$45 copay (provider’s office) / 30% coinsurance (hospital)
Out of Network
50% coinsurance
Inpatient Services
In Network Preferred
Free
In Network
30% coinsurance
Out of Network
50% coinsurance
There is a $500 penalty for failure to obtain prior authorization. If non-recommended providers/facilities are used on non-emergency services, a 25% benefit payment reduction penalty will apply.
Virtual Mental Health
This plan includes membership with Amaze, providing unlimited access to providers 24/7 with no cost for a wide range of virtual services. Other members of your household, such as a spouse and children under 26, are still eligible for Amaze if even they are not on the plan with you.
Amaze mental health professionals provide immediate and responsive interventions such as bridge therapy and medication management. They also assist in finding the right care for you and your financial situation, should you need additional support.
Therapist
$0/visit
Amaze provides services in psychiatry, psychology, and medical management following a mental health prevention model. Treatment plan and length is determined by the medical professional.
Psychiatrists
$0/visit
Amaze provides services in psychiatry, psychology, and medical management following a mental health prevention model. Treatment plan and length is determined by the medical professional.
Pregnancy & Birth
This plan covers services provided before and after your child is born.
In Network Preferred
In Network
Out of Network
There are dozens of preventive care services available for free with this plan, including check-ups, counseling, screenings, and immunizations. These services are government mandated. To learn more, scroll down to the Free Preventive Care section below.
Labor, delivery, hospital stay
In Network Preferred
Free
In Network
30% coinsurance
Out of Network
N/A
This includes labor, delivery (including c-section), and recovery needed at a hospital. Prior authorization may be required for stays exceeding 48 hours.
Telemedicine
All plans include membership with telemedicine, providing unlimited access to a physician 24/7 with no cost for general medical visits.
Everyday Care
$0/visit
Physicians are available 24/7 for your family. Speak with a physician for conditions like the flu, pink eye, rashes, and much more.
Specialist Guidance
$0/visit
Speak with a physician about conditions related to orthopedic, cardiology, and dermatology services.
Mental Health
$0/visit
Amaze mental health professionals provide immediate and responsive interventions such as bridge therapy and medication management. They also assist in finding the right care for you and your financial situation, should you need additional support.
Amaze provides services in psychiatry, psychology, and medical management following a mental health prevention model. Treatment plan and length is determined by the medical professional.
Nutrition and Wellness
$0/visit
Free Clinical Preventive Care
Every plan includes over 74 preventive care services that are completely free on day one. These services keep you healthy before you become sick, including routine check-ups, counseling, screenings, and immunizations. For information on services covered click here.
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