Summary of Benefits and Coverage:
What the Plan Covers and Costs

DC37 Med Team | DC37 Med Team (Active/Retiree)

Benefits Summary: DC37 Med-Team
Medical Care Your In-Network Cost Your Out-of-Network Cost
PCP office visit $25 copay Reimbursement subject to out-of-network deductible. Coinsurance maximum noted below.
Specialist office visit $25 copay
Diagnostic lab/X-ray $25 copay
Routine physical exam $0 copay
Well child care $0 copay
Outpatient mental health $25 copay
Urgent care $50 copay
Ambulatory surgery $0
Ambulance Reimbursement at 100% of the allowed charge
Inpatient care $0 copay
Anesthesia $10
Emergency room $150 copay (waived if admitted) $150 copay (waived if admitted)
Cost Sharing In-Network Out-of-Network
Annual deductible $0 $1,000 individual/$3,000
Annual coinsurance $0 30% to $7,150 individual/$14,300 family
Out-of-network
annual maximum
Not applicable Unlimited
Out-of-network lifetime maximum Not applicable Unlimited