Network Office Visits and Routine Lab Services
You pay a set dollar amount (co-payment) for frequently used services like network doctor office visits. PCP 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 do not count 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.
Free in-network Primary Care Physician (PCP) visits
For both preventive/wellness check ups and sick visits, even for non-preventive care, your PCP visits are covered in-network at 100%. Make sure you designate a PCP early in the year.
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, including prescription drug copays, 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 out-of-pocket maximum. Here's how it works: When your out-of-pocket expenses (deductible, co-insurance and co-pays) reach the out-of-pocket maximum, the plan pays the full cost for any covered care you receive for the rest of the year. Penalties do not count toward reaching your annual 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
- Contraception and lactation counseling