Copay alignment option

The copay alignment option equalizes copays with the costs of services. Simply put, the higher the cost of the service, the higher the cost of the copay. For example:

• Specialist visits are $15 more than primary care visits.  Learn more about primary vs. specialist copays.
  
• Urgent care copay is $30 more than the primary care copay. Learn more about the urgent care copay.
  
• ER copay is $100.
• Advanced diagnostic imaging copay is $150, limited to a maximum of 10 copays per member per plan year. Learn more about the advanced diagnostic imaging copay.

This option can be offered upon renewal of any group (two or more individuals) HMO, POS and PPO plan, except if the plan is offered with an HSA.

Aligned Copay Structure
Plan	Primary Care	Specialist Care	Urgent Care	ER	Advanced Diagnostic Imaging
Level 1*	$10	$25	$40	$100	$150
Level 2	$15	$30	$45	$100	$150
Level 3	$20	$35	$50	$100	$150
Level 4*	$25	$40	$55	$100	$150
Level 5	$30	$45	$60	$100	$150

*Limited to non-reform groups of more than 50 eligible employees.

Deductibles and coinsurance under copayment aligned plans

• Office visits are copay only. Copay does not apply to the member's deductible.
• Preventive care lab costs are covered in full and do not apply to the deductible.
• Lab tests performed in a physician's office are covered in full and do not apply to the deductible.

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Primary care vs. specialist care copays

Under an HMO or POS plan, the primary care copay applies to visits to the member's designated primary care physician. Under a PPO plan, the primary care copay applies to visits to primary care physicians and other primary care providers, including:

• Family practice
• General practice
• Gynecology
• Internal medicine
• Obstetrics & gynecology (not all OB/Gyns are primary care physicians; see below)
• Pediatrics
• Internal medicine/pediatrics

Any other provider is considered a specialist.  Check the online Find a Doctor tool to find primary care physicians and other primary care providers by category.
 
OB/Gyn care

• HMO or POS plans: If the OB/Gyn is the employee's primary care physician, the primary care copay applies. If he/she is not your PCP, the specialist copay applies (except for routine maternity care).
• PPO plans: A physician must be classified in the Priority Health system as a primary care physician to have the primary care copay apply. Not all OB/Gyns are classified as primary care providers. Check the online Find a Doctor tool and search for Primary Care to find OB/Gyns who are classified as primary care physicians.
• Routine maternity care: The primary care copay applies to all routine maternity services, with a maximum of four primary-care copays per pregnancy for routine prenatal and postnatal services.
  

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Urgent care copays

The urgent care copay applies to visits to all types of urgent care centers.

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Advanced diagnostic imaging copays

• Advanced diagnostic imaging tests include CT (CAT), MRI, MRA, advanced cardiac imaging and PET scans.
• This copay applies to tests done on an outpatient basis. Use of the ER is considered an outpatient visit.
• Employees will be charged a maximum of 10 such copays per individual per year. After that, the tests will be covered at 100%.
• There is no copay for these tests when the member is receiving inpatient hospital care. Any member coinsurance payment for the tests will apply to his/her deductible.
• If tests are performed under separate CPT codes (such as upper and lower back or chest and abdomen), the employee will be charged a separate copay for each test billed. 

Note: Advanced diagnostic imaging done anywhere other than the ER requires prior authorization from the prescribing physician. If prior notification is not received, a $250 penalty applies.