The table below lists what you will pay for common services received out-of-network in the Access Plan. Your Certificate of Coverage (ET-2180) and Access Plan Schedule of Benefits detail all of your benefits.

The Access Plan and Access HDHP use the nationwide First Health provider network. In Southern Wisconsin, members also have access to Dean Health Plan providers. Visit the Locate a Provider page to confirm your provider is in-network. If you choose to seek care from an out-of-network provider, you will be responsible for paying higher out-of-pocket costs.

Regular out-of-network services are only available through the Access Plan and Access HDHP. Except for the State Maintenance Plan (SMP), the IYC Health Plan and High Deductible Health Plan offer coverage for out-of-network services only with prior authorization from your health plan. 
 

Access Plan

Access HDHP

Annual Medical Deductible

Individual / Family

Counts toward out-of-pocket limit (OOPL)

$500 / $1,000

Medical deductible does not apply to prescription drugs

After an individual within a family plan meets the $500 deductible, benefits apply as described below

Combined medical and prescription drugs

$2,000 / $4,000

Must be met before coverage begins

Families: Must meet full family deductible before benefits apply as described below

Annual Medical Coinsurance

Applies to medical services except for emergency room copayments

After deductible: You pay 30% up to OOPL

After deductible: You pay 30% up to OOPL

Medical Out-of-Pocket Limit (OOPL)

Individual / Family

$2,000 / $4,000

Does not apply to prescription drugs

$3,800 / $7,600

Combined medical and prescription drugs

Families: Must meet full family OOPL before your plan pays 100%

Primary Care Office Visit

Additional services such as lab work, X-rays, etc., count toward the deductible and coinsurance

Includes:

  • Internist
  • General Physician
  • Family Practitioner
  • Pediatrician
  • Gynecologist / Obstetrician
  • Nurse Practitioner
  • Physician Assistant
  • Chiropractor
  • Physical / Occupational / Speech Therapy in an office visit setting

100% until deductible is met

After deductible: You pay 30% up to OOPL

100% until deductible is met

After deductible: You pay 30% up to OOPL

Specialty Office Visit

Additional services such as lab work, X-rays, etc., count toward the deductible and coinsurance

Includes:

  • Specialty Providers
  • Urgent Care
  • Vision Exam in an office visit setting

100% until deductible is met

After deductible: You pay 30% up to OOPL

100% until deductible is met

After deductible: You pay 30% up to OOPL

Preventive Services

See healthcare.gov/preventive-care-benefits

You pay deductible and/or coinsurance

You pay deductible and/or coinsurance

Emergency Room

Copay waived if admitted as an inpatient directly from the emergency room or for observation for 24 hours or longer.

$75 copay per visit

Copay counts toward in-network OOPL

In-network deductible and coinsurance may apply to services beyond the copay, up to OOPL

100% until in-network deductible is met

After in-network deductible: $75 copay per visit

Copay counts toward in-network OOPL

In-network deductible and coinsurance may apply to services beyond the copay, up to OOPL

Mental Health/Alcohol and Drug Abuse

Additional services such as lab work, assessments, etc., are subject to deductible and coinsurance

100% until deductible is met

After deductible: You pay 30% up to OOPL

100% until deductible is met

After deductible: You pay 30% up to OOPL
Transplants

100% until deductible is met

After deductible: You pay 30% up to OOPL

100% until deductible is met

After deductible: You pay 30% up to OOPL