Page 5 - CPC Behavioral Healthcare 2022 - 2023 Benefits Guide

MEDICAL PLANS

CPC Behavioral Healthcare provides you with a choice of three medical plan options. The chart below represents
what you pay when using the plan:

Advantage EPO
POS Design 10 Direct Access Design 1
Plan
Plan Provision
Out-of- Out-of-
In-Network ONLY In-Network Network In-Network Network
Annual Deductible
(Individual/Family) $1,000/$2,000 N/A $2,000/$4,000 N/A $2,000/$4,000
Out-of-Pocket Maximum (Includes
Deductible) $3,500/$7,000 $5,000/$10,000 $5,000/$10,000 $5,000/$10,000 $5,000/$10,000

Lifetime Maximum
Unlimited

Preventive Care 40% after 20% after
0% 0% deductible 0% deductible

Primary Physician Office Visit 40% after 20% after
$20 copay $15 copay deductible $15 copay deductible

Specialist Office Visit 40% after 20% after
$40 copay $25 copay deductible $25 copay deductible
Office-No Charge
X-Ray and Lab Independent Facility- 40% after 20% after
0% 0%
20% after deductible deductible
deductible
$200 copay $200 copay
Inpatient Hospital Services then 40% after then 20% after
20% after deductible $200 copay $200 copay
deductible deductible

Outpatient Hospital 20% after deductible 0% 40% after 0% 20% after
Services/Surgery deductible deductible

Urgent Care 40% after 20% after
$40 copay $25 copay deductible $25 copay deductible

Emergency Room Care
$100 copay then 20% $50 copay $50 copay

Retail Prescription Drugs
(30-day supply)
• Generic $15 copay $15 copay $15 copay
• Brand Preferred $35 copay $35 copay Not Covered $35 copay Not Covered
• Brand Non-preferred $50 copay $50 copay $50 copay

Mail Order Prescription Drugs
(90-day supply)
• Generic $30 copay $30 copay $30 copay
• Brand Preferred $70 copay $70 copay Not Covered $70 copay Not Covered
• Brand Non-preferred $100 copay $100 copay $100 copay

Above Chart Depicts What YOU Pay
Note: This is a summary of your coverage only.
In-network services are based on negotiated charges; out-of-network services are subject to balance billing.

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