What is a copay? A copay (or copayment) is a flat fee that you pay on the spot each time you go to your doctor or fill a prescription. For example, if you hurt your back and go see your doctor, or you need a refill of your child's asthma medicine, the amount you pay for that visit or medicine is your copay. Family physicians are sometimes reluctant to add this second service because they know the patient will be charged a copay or, depending on the deductible, the full fee for the problem-oriented visit.
The following chart gives an overview of the differences between the four medical plans.
| Duke Select (HMO) | Duke Basic (HMO) | Blue Care Blue Cross NC (HMO) | Duke Options Blue Cross Blue Shield (PPO) | ||
|---|---|---|---|---|---|
| In-Network | Out-of- Network | ||||
| Annual Deductible | |||||
| Individual | None | $6001 | None | $1301 | $650 |
| Family | None | $1,8001 | None | $3901 | $1,950 |
| Co-Insurance Maximum | |||||
| Individual | None | $2,0002 | None | $2,0002 | $4,0002 |
| Family | None | $6,0002 | None | $6,0002 | $12,0002 |
| Physician Office Visit | |||||
| PCP | $20 co-pay | $25 co-pay | $20 co-pay | $20 co-pay | You pay 30% after deductible3 |
| Specialist | $55 co-pay | $75 co-pay | $55 co-pay | $55 co-pay | You pay 30% after deductible3 |
| MRI, CT, PET Scan | $150 co-pay | $150 co-pay | Covered in full | You pay 10% after deductible | You pay 30% after deductible3 |
| Lab & Other X-Ray | Covered in full | Covered in full | Covered in full | You pay 10% after deductible | You pay 30% after deductible3 |
| Annual Physical | $20 co-pay primary care $55 co-pay specialist | $25 co-pay primary care $75 co-pay specialist | $20 co-pay primary care $55 co-pay specialist | $20 co-pay primary care $55 co-pay specialist | Well visits not covered; you pay 30% after deductible3 for annual PAP smear, mammogram, or PSA |
| Mammogram | Covered in full | Covered in full | Covered in full | Covered in full | You pay 30% after deductible3 |
| Colonoscopy | Covered in full | Covered in full | Covered in full | Covered in full | You pay 30% after deductible3 |
| OB/GYN Exams | $20 co-pay primary care $55 co-pay specialist | $25 co-pay primary care $75 co-pay specialist | $20 co-pay | $20 co-pay primary care $55 co-pay specialist | Well visits not covered; you pay 30% after deductible3 for PAP smear, mammogram, and sick visits |
| Well Baby Visits (under age 2) | Covered in full | Covered in full | $20 co-pay primary care $55 co-pay specialist | $20 co-pay primary care $55 co-pay specialist | Not covered |
| Maternity Care: includes prenatal and post-delivery care | $20 co-pay primary care or $55 co-pay specialist first visit, then professional services covered in full | $75 co-pay specialist first visit, then professional services covered in full | $20 co-pay first visit, then professional services covered in full | $20 co-pay primary care or $55 co-pay specialist first visit, then professional services covered in full | You pay 30% after deductible3 for professional services |
| Hospital Care | |||||
| Inpatient | $600 per admission co-pay4, then covered in full | Subject to $600 annual deductible; you pay 10% co-insurance up to maximum of $2,0001 | $600 or $700 per admission co-pay5, then covered in full | After $600 or $700 per admission co-pay5 and deductible, you pay 10% up to maximum of $2,000 | 70% after $900 per admission co-pay and deductible3 |
| Outpatient | $250 co-pay | You pay 10% after deductible | $250 co-pay | You pay 10% after deductible | You pay 30% after deductible3 |
| Emergency Care | $250 co-pay, waived if admitted | $250 co-pay, waived if admitted | $250 co-pay, waived if admitted | $250 co-pay, waived if admitted | $250 co-pay, waived if admitted |
| Urgent Care | $35 co-pay | $50 co-pay | $35 co-pay | $35 co-pay | $35 co-pay |
| Ambulance | Covered in full when medically necessary | You pay 20% after deductible | Covered in full when medically necessary | You pay 10% after deductible when medically necessary | You pay 10% after deductible when medically necessary |
| Other Services | |||||
| Infertility | Provided only at the Duke Fertility Center for employees with two years of service; limits apply6 | Not covered | Does not include COH, IVF, or other types of artificial conception6 | Provided only at the Duke Fertility Center for employees with two years of service; limits apply6 | Not covered |
| Infertility Testing and Treatment, Subject to Precertification | Fixed price; precertification required; limits apply6 | Not covered | $20 co-pay primary care; $55 co-pay specialist; covered in full for testing6 | Fixed price; precertification required; limits apply6 | Not covered |
| Skilled Nursing Facility | Covered in full when authorized by doctor; 60-day annual maximum | Covered in full when authorized by doctor; 60-day annual maximum | Covered in full when authorized by doctor; 60-day annual maximum | You pay 10% after deductible when authorized after $250 per admission co-pay; 60-day annual maximum | You pay 30% after deductible3 when authorized after $250 per admission co-pay; 60-day annual maximum |
| Home Health Care | Covered in full when authorized by doctor; up to 100 visits per calendar year | $25 co-pay per visit when authorized by doctor; up to 100 visits per calendar year | Covered in full when authorized by doctor; up to 100 visits per calendar year | You pay 10% after deductible when authorized; 100 combined in- and out-of-network visits per calendar year | You pay 30% after deductible3 when medically necessary; 100 combined in- and out-of-network visits per calendar year |
| Hospice Care | Covered in full when authorized by doctor | Covered in full when authorized by doctor | Covered in full when authorized by doctor | You pay 10% after deductible | You pay 30% after deductible3 |
| Durable Medical Equipment | You pay 10% | You pay 20% after deductible | Covered in full | You pay 10% after deductible7 | You pay 30% after deductible3 |
| Prosthetics | You pay 10% | You pay 20% after deductible | Covered in full | You pay 10% after deductible | You pay 30% after deductible3 |
| Physical Therapy (PT) Occupational Therapy (OT) | $20 co-pay; 40 visits per injury or illness each calendar year for combined PT and OT7 | $75 co-pay; 40 visits per injury or illness each calendar year for combined PT and OT | $55 co-pay for PT and OT; 40 visits per calendar year for combined PT and OT7 | $55 co-pay; 40 visits per calendar year for combined PT, OT, and chiropractic in- and out-of-network7 | You pay 30% after deductible; 40 visits per calendar year for combined PT, OT, and chiropractic in- and out-of-network3 |
| Chiropractic Care | $55 co-pay | $75 co-pay | $55 co-pay; 20 visits per calendar year | $55 co-pay; 40 visits per calendar year for combined PT, OT, and chiropractic in- and out-of-network | You pay 30% after deductible3; 40 visits per calendar year for combined PT, OT, and chiropractic in- and out-of-network |
| Nutrition | $20 co-pay; 6 visits per calendar year | $25 co-pay; 6 visits per calendar year | Covered in full up to 6 visits per calendar year | Covered in full up to 6 visits per calendar year | Not covered |
| Speech Therapy | $20 co-pay; 20 visits per calendar year; precertification required7 | $75 co-pay; 20 visits per calendar year; precertification required | $55 co-pay; 20 visits per calendar year | $55 co-pay; 20 visits per calendar year for combined in- and out-of-network7 | You pay 30% after deductible3; 20 visits per calendar year for combined in- and out-of-network |
| Vision Exam | $55 co-pay; limit 1 per calendar year | $75 co-pay; limit 1 per calendar year | $20 co-pay; limit 1 per calendar year; 30% lens and frame discount at point of purchase; 15% disposable contacts discount at point of purchase | $55 co-pay; limit 1 per calendar year; 30% lens and frame discount at point of purchase; 15% disposable contacts discount at point of purchase | Not covered |
| Bariatric Surgery8 | $2,500 surgical co-pay | Not covered | $2,500 surgical co-pay | $2,500 surgical co-pay | Not covered |
- Deductible does not apply to office visits for primary care and specialist.
- Excluding deductibles, co-pays, prescription drug co-pays, urgent care and emergency room co-pays and developmental disabilities co-pays and co-insurance.
- All payments are based on the allowable charge. You are liable for charges over the allowable charge when receiving out-of-network services.
- Wake Med is considered in-network for only certain services including OBGYN, Pediatrics, rehabilitation, and ER.
- $600 per admission co-pay for Duke Hospital, Duke Regional Hospital, and Duke Raleigh Hospital facilities and $700 for all others in-network.
- See the Member Guide and Summary of Benefits and Coverage for details.
- For children under 18 with significant disability, the plan will pay 100 percent for in-network benefits after appropriate co-pay per visit to an annual maximum of $10,000 in charges for employees hired prior to January 1, 1997. After $10,000 in charges, the plan pays 75 percent. Treatment must be received at Duke Hospital and its outpatient clinics.
- For qualified patients only. See Summary of Benefits and Coverage for details.
Questions to Ask: Making Your Medical Plan Decisions
Formatting text for app surfaces | Slack. When comparing Duke's medical plans, it is important to compare the cost of out-of-pocket expenses as well as premiums. Here are some questions to ask yourself in choosing a medical plan that matches the needs of you and your family.
Do You Have To Pay A Copay For A Physical
Copay For Annual Physical Exam
| Duke Select (HMO) | Duke Basic (HMO) | Blue Care Blue Cross NC (HMO) | Duke Options (Blue Cross Blue Shield PPO) | ||
|---|---|---|---|---|---|
| In-Network | Out-of- Network | ||||
| Can I select any doctor I wish? | No | No | No | No | Yes |
| Will my child's pregnancy be covered? | No | No | Yes | Yes | No |
| Will my dependent children who live in a different location be covered? | Emergency/urgent care only. No follow-up care. | Emergency/urgent care only. No follow-up care. | Yes, if within NC and in-network - otherwise, emergency care only | Yes, worldwide listing of doctors | Yes |
| Since I travel a lot, can I see doctors in other locations around the world? | Emergency/urgent care only. No follow-up care. | Emergency/urgent care only. No follow-up care. | Emergency/urgent care only. No follow-up care. | Yes, worldwide listing of doctors | Yes |
| Can I participate in the DukeWELL care management program? | Yes, if you have certain medical conditions | Yes, if you have certain medical conditions | No | No | No |
| Are there out-of network benefits? | 20 visits out-of-network limit for behavioral health. Emergency/urgent care out-of-network | 20 visits out-of-network limit for behavioral health. Emergency/urgent care out-of-network | 20 visits out-of-network limit for behavioral health. Emergency/urgent care out-of-network | Yes, under out-of-network benefits | Yes |
| Must I meet an annual deductible? | No | Yes, for some services | No | Yes, for some services | Yes |
| Do all plans cover the same services? | Special Services include: Bariatric and Infertility | No special services covered | Special Services include: Bariatric and dependent pregnancy | Special Services include: ABA Therapy, Bariatric, Infertility, International health services, Transgender surgery, and dependent pregnancy | Special Services include: ABA Therapy, International health services, Transgender surgery, and dependent pregnancy |