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Does not provide out of network. Exclusive Provider Organization (EPO)-insurance plan allows access to health care from a network physician, facility or other health care professional, including specialists, without designating a Primary Physician or obtaining a referral- there is no claim forms or bills.
EPO - Premium Network. Specialist: $30 Copayment per visit. Deductible: $0 / $0 Emergency Department: $125 Copayment per visit. Coinsurance: 10%. Total AnnualalsoOut-of-Pocket: $1,000 / $2,000. This document is your Schedule of Benefits. If you. enroll in this plan, this Schedule of Benefits will be an. important part of your Certificate of Coverage (COC). Your plan may include a SummaryPlan. Description (SPD). If your plan has an SPD, it is issued. by your employeror labor trust fund.