Major Medical Copay 10000
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/RBP
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 guaranteed.
Tier 2: In Network
Find a participating provider using the 6 Degrees Health network. Book a call to find participating providers near you. If you are a member, log in to your member portal to find a provider.
Hospital Services
For hospitals and facilities, the Maximum Allowable Charge paid by your plan is based on a reference-based price. Reference-based pricing works by reimbursing hospitals and facilities based on objective criteria. Most commonly, the criteria will be Medicare-published costs and pricing data, plus an additional percentage. This allows for a reasonable reimbursement that is fair to the hospital and facility, and a savings to the plan. 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
$10,000
Out of Network
Not covered
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
$20,000
Out of Network
Not covered
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
$10,000
In Network
$10,000
Out of Network
Not covered
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
$20,000
In Network
$20,000
Out of Network
Not covered
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
Free (through select partner)
In Network
$50 copay
Out of Network
Not covered
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.
$0 primary care is available through the plan's telemedicine partner.
Specialist visit
In Network Preferred
N/A
In Network
$100 copay (office visit) / 50% coinsurance (outpatient hospital)
Out of Network
Not covered
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). Referrals are not needed to see specialists.
Other services performed in a physician’s office setting (including but not limited to minor surgery or procedures) are subject to deductible and coinsurance.
Urgent Care
In Network Preferred
Free (through select partner)
In Network
$100 copay (office) / 50% coinsurance (hospital)
Out of Network
Not covered
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.
$0 care may be available through the plan's telemedicine partner. Tier 1 benefits are not guaranteed.
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
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.
Preferred Brand
In Network Preferred
N/A
In Network
$0 copay
Out of Network
Not covered
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
Not covered; discount card available.
Out of Network
Not covered
Generally these are higher-cost drugs that have recently come on the market. In most cases, an alternative preferred drug is available.
Visit writewiserx.americaspharmacy.com to access your Discount Card.
Specialty
In Network Preferred
N/A
In Network
Not covered; discount card available.
Out of Network
Not covered
A specialty drug is a high-cost medication used to treat a chronic or complex health condition.
Visit writewiserx.americaspharmacy.com to access your Discount Card.
In Network Preferred
In Network
Out of Network
X-rays
In Network Preferred
Free
In Network
50% coinsurance
Out of Network
Not covered
This includes the use of X-rays to diagnose a condition.
Prior authorization is required for access to benefits. If non-recommended providers/ facilities are used on non-emergent services, a 25% payment reduction penalty will apply at the plan’s discretion. For certain services, the Plan may require the use of a Designated Provider or Designated Site of Care. In certain instances, services obtained elsewhere may not be covered.
Tier 1 benefits are not guaranteed.
Imaging (CT/PET/MRI)
In Network Preferred
Free
In Network
50% coinsurance
Out of Network
Not covered
Imaging includes diagnostic services such as CT scans, PET scans, and MRIs.
Prior authorization is required for access to benefits. If non-recommended providers/ facilities are used on non-emergent services, a 25% payment reduction penalty will apply at the plan’s discretion. For certain services, the Plan may require the use of a Designated Provider or Designated Site of Care. In certain instances, services obtained elsewhere may not be covered.
Tier 1 benefits are not guaranteed.
Labs/Bloodwork
In Network Preferred
N/A
In Network
50% coinsurance
Out of Network
Not covered
Blood tests are often used to help diagnose a condition, or check levels such as cholesterol or blood sugar.
In Network Preferred
In Network
Out of Network
Emergency Room
In Network Preferred
N/A
In Network
50% 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.
Notification is required if admitted as inpatient, or as soon as reasonably possible, and inpatient benefits will apply.
Ambulance
In Network Preferred
N/A
In Network
50% 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. ALS and Air Ambulance are only covered when medically necessary and the only option.
*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
N/A
In Network
50% coinsurance
Out of Network
N/A
This is the amount you’re responsible for when using the facilities and equipment at a hospital.
Prior authorization is required for access to benefits. If non-recommended providers/facilities are used on non-emergent services, a 25% payment reduction penalty will apply at the plan’s discretion. For certain services, the Plan may require the use of a Designated Provider or Designated Site of Care. In certain instances, services obtained elsewhere may not be covered.
Hospital stay (physician)
In Network Preferred
N/A
In Network
50% coinsurance
Out of Network
Not covered
This is the amount you’re responsible for when receiving services provided by a physician, surgeon, medical doctor, or other specialists.
Prior authorization is required for access to benefits. If non-recommended providers/facilities are used on non-emergent services, a 25% payment reduction penalty will apply at the plan’s discretion. For certain services, the Plan may require the use of a Designated Provider or Designated Site of Care. In certain instances, services obtained elsewhere may not be covered.
Outpatient procedure (facility)
In Network Preferred
Free
In Network
50% 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.
Prior authorization is required for access to benefits. If non-recommended providers/facilities are used on non-emergent services, a 25% payment reduction penalty will apply at the plan’s discretion. For certain services, the Plan may require the use of a Designated Provider or Designated Site of Care. In certain instances, services obtained elsewhere may not be covered.
Tier 1 benefits are not guaranteed.
Physical rehabilitation
In Network Preferred
Free
In Network
$100 copay
Out of Network
Not covered
Rehabilitation & Habilitation have a combined limit of 30 days per plan year.
Prior authorization is required for access to benefits. If non-recommended providers/facilities are used on non-emergent services, a 25% payment reduction penalty will apply at the plan’s discretion. For certain services, the Plan may require the use of a Designated Provider or Designated Site of Care. In certain instances, services obtained elsewhere may not be covered.
Tier 1 benefits are not guaranteed.
In Network Preferred
In Network
Out of Network
Outpatient Services
In Network Preferred
Free (through select partner)
In Network
$50 copay (provider’s office) / 50% coinsurance (hospital)
Out of Network
Not covered
$0 care may be available through the plan's telemedicine partner. Tier 1 benefits are not guaranteed.
Inpatient Services
In Network Preferred
Free
In Network
50% coinsurance
Out of Network
N/A
Prior authorization is required for access to benefits. If non-recommended providers/facilities are used on non-emergent services, a 25% payment reduction penalty will apply at the plan’s discretion. For certain services, the Plan may require the use of a Designated Provider or Designated Site of Care. In certain instances, services obtained elsewhere may not be covered.
Tier 1 benefits are not guaranteed.
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
50% 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.
If non-recommended providers/facilities are used on non-emergent services, a 25% payment reduction penalty will apply at the plan’s discretion. For certain services, the Plan may require the use of a Designated Provider or Designated Site of Care. In certain instances, services obtained elsewhere may not be covered.
Tier 1 benefits are not guaranteed.
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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