Copayments/Deductibles

Use this table to enter any copayments, deductibles, or out-of-pocket amounts that are required for this benefit plan. These fields are for information only and this table is optional.

Contents

Field	Description
Copay/Deductible Type	Enter up to 15 alphanumeric characters to uniquely identify the type of copayment or deductible. For example, you might specify a copayment for an expense that is In the Network or one that is Out of Network.
Office Visit Copay	Enter the copay amount this benefit plan requires for an office visit.
Specialist Visit Copay	Enter the copay amount this benefit plan requires for a specialist visit.
Preventive Care Copay	Enter the copay amount this benefit plan requires for a preventive care visit.
Brand Prescriptions	Enter the copay amount this benefit plan requires for a brand prescription.
Generic Prescriptions	Enter the copay amount this benefit plan requires for a generic prescription.
Individual Deductible	Enter the annual deductible amount this benefit plan requires for an individual. You can enter an amount as large as $9,999,999,999.00.
Family Deductible	Enter the annual deductible amount this benefit plan requires for a family.
Employee Pmnt After Deductible	Enter for the percentage (not to exceed 100.00%) the employee must pay for medical expenses incurred after the annual deductible has been met.
Indiv Max Out of Pocket	Enter the maximum annual amount this benefit plan requires an individual to pay "out-of-pocket."
Family Max Out of Pocket	Enter the maximum annual amount this benefit plan requires a family to pay "out-of-pocket."
Comments	Enter any additional comments about this benefit plan.