{"id":3112,"date":"2021-10-23T09:59:13","date_gmt":"2021-10-23T09:59:13","guid":{"rendered":"https:\/\/myaci-benefits.com\/?page_id=3112"},"modified":"2025-04-04T09:31:33","modified_gmt":"2025-04-04T16:31:33","slug":"epo","status":"publish","type":"page","link":"https:\/\/myaci.altimateqod.com\/us\/health\/epo\/","title":{"rendered":"EPO HP-Network Plan \/ EPO Network Plan"},"content":{"rendered":"

If you wish to enroll in the EPO Plan and you live in a high-performance network location, you can choose the EPO HP-Network Plan. Otherwise you can choose the EPO Network Plan.<\/p>\n<\/div><\/div><\/div>

\n

EPO Plan<\/strong>
<\/p><\/div><\/div><\/td><\/tr>

Where Available<\/strong>
<\/p>


<\/p>

<\/p><\/div><\/div><\/td>

Nationwide except HI, EPO HP-Network in select locations nationwide
Find BCI providers in your area<\/a><\/strong>.
<\/p>


<\/p>


<\/p>

<\/p><\/div><\/div><\/td><\/tr>

Annual Deductible<\/strong>
<\/p>

- Associate<\/p>

- Family<\/p>

<\/p><\/div><\/div><\/td>

Embedded
<\/p>

$1,500<\/p><\/div><\/div>

$4,500<\/p><\/body><\/html><\/div><\/div><\/td><\/tr>

Annual Out-of-Pocket Max<\/strong>
<\/p>

- Associate<\/p>

- Family<\/p><\/div><\/div><\/td>

Embedded<\/p>

$5,000<\/p>

$15,000<\/p><\/div><\/div><\/td><\/tr>


<\/p><\/div><\/div><\/td>

IN-NETWORK - YOU PAY<\/strong><\/p><\/div><\/div><\/td><\/tr>

Preventive Care<\/strong>
<\/p><\/div><\/div><\/td>

$02<\/sup><\/p><\/body><\/html><\/div><\/div><\/td><\/tr>

Teladoc Telemedicine Visit<\/strong>
<\/p>

- Medical<\/p>

- Mental Health<\/p><\/div><\/div><\/td>


<\/p>

$20 per visit
<\/p>

$20 per visit
<\/p><\/div><\/div><\/td><\/tr>

Office Visit<\/strong>
<\/p>

- PCP<\/p>

- Specialist<\/p><\/div><\/div><\/td>

<\/p><\/div><\/div>

$20 copay3<\/sup><\/p><\/body><\/html><\/div><\/div>

$40 copay3<\/p><\/body><\/html><\/div><\/div><\/td><\/tr>

Urgent Care<\/strong>
<\/p><\/div><\/div><\/td>

$40 copay3<\/p><\/body><\/html><\/div><\/div><\/td><\/tr>

Emergency Room<\/strong>
<\/p><\/div><\/div><\/td>

$200 copay + 30%2<\/sup><\/p><\/body><\/html><\/div><\/div><\/td><\/tr>

Diagnostic Testing<\/strong>
<\/p><\/div><\/div><\/td>

PCP office: $20 copay3<\/sup><\/p><\/body><\/html><\/div><\/div>

Specialist office: $40 copay3<\/sup><\/p><\/body><\/html><\/div><\/div><\/td><\/tr>

Outpatient X-Ray and Lab<\/strong>
<\/p><\/div><\/div><\/td>

PCP office: $20 copay3<\/p><\/body><\/html><\/div><\/div>

Specialist office: $40 copay3<\/p><\/body><\/html><\/div><\/div><\/td><\/tr>

Hospitalization<\/strong><\/p>

- Inpatient Semi-Private Room<\/p>

- Inpatient Physician<\/p>

<\/p><\/div><\/div><\/td>

<\/p><\/div><\/div>

30%2<\/sup><\/p><\/body><\/html><\/div><\/div>

30%2<\/sup><\/p><\/body><\/html><\/div><\/div><\/td><\/tr>

Outpatient Treatment<\/strong>
<\/p>

(Physical, Occupational & Speech Therapy)<\/p><\/div><\/div><\/td>

$40 copay3<\/sup><\/p><\/body><\/html><\/div><\/div>

<\/p><\/div><\/div><\/td><\/tr>

Mental Health\/Substance Abuse<\/strong>
<\/p>

- Inpatient<\/p>

- Outpatient<\/p><\/div><\/div><\/td>

<\/p><\/div><\/div>

30%2<\/sup><\/p><\/body><\/html><\/div><\/div>

$20 copay3<\/sup> (Outpatient psychotherapy)<\/p><\/body><\/html><\/div><\/div><\/td><\/tr>

Pharmacy Retail
<\/p><\/div><\/div><\/td>

30-day supply
<\/p><\/div><\/div><\/td><\/tr>

- Annual Deductible Applies
<\/p>

- Pharmacy Out-of-Pocket Max<\/p><\/div><\/div><\/td>

No
<\/p>

Combined with medical<\/p>

<\/p><\/div><\/div><\/td><\/tr>

<\/p>

$0 copay
$10 copay
<\/p>

<\/p>

<\/p>

<\/p>

<\/p>

<\/p>

<\/p>

20% (min $30, max $90)<\/p>

30% (min $60, max $120)<\/p><\/div><\/div><\/td><\/tr>

Pharmacy Retail\/Mail Order
<\/p><\/div><\/div><\/td>

90-day supply<\/p><\/div><\/div><\/td><\/tr>

$0 copay
$30 copay
<\/p>

20% (min $90, max $270)<\/p>

30% (min $180, max $360)<\/p><\/div><\/div><\/td><\/tr><\/tbody><\/table>\n<\/div>\n\n<\/div><\/div><\/div>

1) Coinsurance you pay after you meet the annual deductible unless otherwise noted.<\/span>
\n2) Annual deductible waived.<\/span>
\n
\n<\/span><\/p>\n<\/div><\/div><\/div><\/div><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":1590,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-3112","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/myaci.altimateqod.com\/us\/wp-json\/wp\/v2\/pages\/3112","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/myaci.altimateqod.com\/us\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/myaci.altimateqod.com\/us\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/myaci.altimateqod.com\/us\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/myaci.altimateqod.com\/us\/wp-json\/wp\/v2\/comments?post=3112"}],"version-history":[{"count":9,"href":"https:\/\/myaci.altimateqod.com\/us\/wp-json\/wp\/v2\/pages\/3112\/revisions"}],"predecessor-version":[{"id":8815,"href":"https:\/\/myaci.altimateqod.com\/us\/wp-json\/wp\/v2\/pages\/3112\/revisions\/8815"}],"up":[{"embeddable":true,"href":"https:\/\/myaci.altimateqod.com\/us\/wp-json\/wp\/v2\/pages\/1590"}],"wp:attachment":[{"href":"https:\/\/myaci.altimateqod.com\/us\/wp-json\/wp\/v2\/media?parent=3112"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}