Network Office Visits and Routine Lab Services
You pay a set dollar amount (co-payment) for frequently used services like network doctor office visits. Routine X-ray and lab services are covered at 100%. More complex tests and imaging such as PET and CT scans, MRIs and MRAs are subject to deductible and co-insurance.
Co-payments count toward the annual co-insurance out-of-pocket maximum, but not towards your annual deductible. They are eligible Flexible Spending Account (FSA) expenses, so you can get reimbursed with pre-tax dollars if you participate in the Health Care FSA.
Other Covered Care
You must first meet the individual or family calendar-year deductible before the plan begins paying most benefits. After the deductible, you pay a percentage of the cost—or co-insurance—for most other care. (Note: copays and prescription drug costs do not count toward the deductible.)
Eligible expenses count toward both your individual and family deductible
- When an individual meets the deductible, the plan begins paying benefits for that person.
- When combined eligible expenses for covered family members reach the family deductible, the plan pays benefits for all covered family members. No additional individual deductible amounts are required that year.
You are protected from catastrophic medical expenses by the annual co-insurance out-of-pocket maximum. When your co-insurance during a calendar year reaches the out-of-pocket maximum, the plan pays the full cost for any covered care you receive for the rest of the year. Medical and prescription copays and co-insurance count towards your medical out-of-pocket maximum. Penalties and deductible amounts do not count toward reaching your annual co-insurance out-of-pocket maximum.
Certain gender reassignment surgery is covered at the same level as other surgeries covered by the plans. Associated prescription drugs required for gender reassignment are also covered as other similarly situated drugs. Covered Medical Expenses include charges in connection with a medically necessary Transgender (Sex Change) Surgery as long as you or a covered dependent have obtained pre-certification from Anthem and meet the plan clinical criteria. This coverage reinforces Capital One’s commitment to diversity and our values.
Also Covered by the Medical Plan
- Hearing aids are up to $2,000 per ear every 24 months