Major Medical Copay 8000 Pro

Your premium is the amount you pay for healthcare benefits each month.

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This type of network is designed to give you the widest number of options for medical providers.

You pay the least if you use In-Network Preferred providers to whom you are referred by our Care Coordination team. You pay more if you use an In-Network provider. You will pay the most if you use an out-of-network provider.

To find a list of In-Network providers, go to the First Health network website.

When selecting a provider, contact the provider's office to verify that they are still in-network with First Health and that the provider's billing NPI# is contracted through the First Health network.

You can get a policy that pays you a fixed amount in the event of a Critical Illness, regardless of what your medical bills are. This will help with your out-of-pocket expenses and other non-medical costs due to this Critical Illness including loss of work, extra child care or anything you want to use it for.

You can get a policy that pays you a fixed amount in the case of an accident to help pay your out-of-pocket expenses or other costs related to an accident. This fixed amount varies by the medical service you receive related to the accident. You may use this amount for any use you deem appropriate.

Summary of Benefits and Coverage (SBC)

Drug Formulary

The amount you could owe during a coverage period for covered health care services before the plan begins to pay.

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.

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.

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.

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 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 plan has a $500 per visit benefit limit.

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 plan has a $500 per visit benefit limit.

Referrals are not needed to see specialists.

Chiropractic services are limited to 12 visits per plan year.

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.

This Rx deductible must be satisfied before your RX copays will apply. Rx Deductible applies on all tiers except Generics.

If you have other family members on the plan, each family member must meet their own individual Rx deductible until the total amount of Rx deductible expenses paid by all family members meets the overall family Rx deductible.

This Rx deductible must be satisfied before your Rx copays will apply. Rx Deductible applies on all tiers except Generics.

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.

Rx Deductible does not apply.

Brand drugs are more expensive than generic drugs. Not every brand drug has a generic equivalent. 

Generally these are higher-cost drugs that have recently come on the market. In most cases, an alternative preferred drug is available.

A specialty drug is a high-cost medication used to treat a chronic or complex health condition.

This includes the use of X-rays to diagnose a condition. The plan has a $500 per visit benefit limit.

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.

Blood tests are often used to help diagnose a condition, or check levels such as cholesterol or blood sugar. The plan has a $500 per visit benefit limit.

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 copay is waived if you are admitted as inpatient.

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.

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.

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.

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.

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.

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.

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.

Talkspace is a digital space for private and convenient mental health support. With Talkspace, you are matched with a recommended, licensed provider based on your preferences and can receive support day and night from the convenience of your device (iOS, Android, and Web). You will continue to work with the same therapist throughout your journey. However, you’re always welcome to switch providers so you can find the perfect fit. 

Talkspace Therapy is available to members ages 13+.

With Talkspace Psychiatry, get private and personalized care from a prescriber who specializes in mental health care and prescription management. Get matched with a prescriber in your state, and schedule Live Video sessions for everything from initial evaluation to ongoing prescription management.

Talkspace Psychiatry is available to members ages 18+.

Members can begin to exchange unlimited messages (text, voice, photo and video) with their personal therapist within days of registration. Therapists are recommended to engage daily during their business hours. Every Talkspace member is granted a complimentary, 10-minute video session to get to know their new therapist. Additional live sessions can also be scheduled.

Talkspace Therapy is available to members ages 13+.

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.

This includes labor, delivery (including c-section), and recovery needed at a hospital. Prior authorization may be required for stays exceeding 48 hours.

Includes general nursing care, up to the semi-private room rate.

Includes hospital miscellaneous expense during hospital confinement or for outpatient

surgery under general anesthetic, such as the cost of the operating room, laboratory tests, x-ray examinations, anesthesia, drugs (excluding take-home drugs) or medicines, therapeutic services and supplies.

Includes inpatient and outpatient; limited to 2x per covered individual per accident.

Limited to 10x per covered individual per accident

Based on actual expenses in addition to emergency room, physical therapy, imaging, ambulance, physician visits and follow-ups.

A 30-day waiting period applies.

Paid once per year per member and per spouse.

Physicians are available 24/7 for your family. Speak with a physician for conditions like the flu, pink eye, rashes, and much more.