Northwest Carpenters Health and Security Plan
Summary of Benefits
This summary shows how the cost for covered services is shared between you and the Carpenters Health and Security Plan. This is only a summary. Refer to the Summary Plan Description for complete information, including exclusions and limitations.
The Plan uses the Aetna Choice provider network. You will pay less if you use a provider in this network. You will pay the most if you use a non-network provider, and you might receive a bill from a provider for the difference between the provider's charge and what your plan pays (balance billing).
| What You Will Pay | |||
| Network Provider | Non-Network Provider | ||
| Deductible (learn more) |
$200 individual $400 family |
Generally, you must pay all the costs from providers up to the deductible amount before this 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. Preventive care and primary care services are covered before you meet your deductible. | |
| Out-of-pocket limit (learn more) |
$4,000 individual $8,000 family |
For out-of-network providers there is no out-of-pocket limit. | The out-of-pocket limit is the most you could pay in a year for covered services. 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. |
| Copayments (learn more) |
Copayments for certain services, premiums, balance-billing charges, non-network coinsurance and copayments, and health care this plan doesn't cover. Even though you pay these expenses, they don't count toward the out-of-pocket limit. | ||
| Physician services | $10 office visit copay and 10% coinsurance | $20 office visit copay and 20% coinsurance | |
| Preventive care, screenings, immunizations | No charge | 20% coinsurance. Subject to deductible. | You may have to pay for services that aren't preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. |
| Diagnostic tests and imaging | 10% coinsurance/test | 20% coinsurance/test | |
| Outpatient surgery | 10% coinsurance | 20% coinsurance | |
| Hospital stay | 10% coinsurance | $200 copay and 20% coinsurance | |
| Mental health, behavioral health, or substance abuse | $10 copay/office visit and 10% coinsurance | $20 copay/office visit and 20% coinsurance | |