Embark is ideal for individuals and families that may seek medical care several times a year. A member’s benefit level is determined by his or her choice of provider and the services received. For example, when a member seeks services from a Preferred network provider, the Category 1 choice (highest benefit level) applies and the member incurs the lowest out-of-pocket cost.

Embark benefits
Embark includes two types of benefits:
• Upfront benefits
• Member cost sharing

Upfront benefits
Embark members have immediate coverage for office visits, including preventive exams and urgent care visits, outpatient radiology and laboratory services. Their deductible is waived for these “upfront” services and coinsurance does not apply.

Upfront office visits

• The first four, six or unlimited office visits per calendar year (depending on the product option selected by the employer group) are not subject to deductible or coinsurance when members see a Preferred or Participating provider.
• Individual copayment options differ depending on the product option selected by the employer group and the member’s choice of provider.
• Copayment options range from $20 to $30 for Preferred or $35 to $45 for  Participating providers.

• A member may access upfront office visits from any provider, as long as the member is within his or her upfront office visit option (four, six or unlimited).
• There are no upfront office visit benefits for non-contracted providers. Office visits to non-contracted providers are subject to deductible and coinsurance. Members may be subject to balance billing.
• Once the upfront office visit limit is reached, members seeing non-contracted providers will be reimbursed 70, 60 or 55 percent (depending on the employer group’s product selection). Members may be subject to balance billing.

Upfront outpatient radiology and laboratory

The first $400 of outpatient radiology and laboratory services from a professional, independent laboratory or facility (excluding inpatient services) per calendar year is covered at 100 percent of the allowed amount and not subject to deductible or coinsurance.

Member cost sharing
Members are responsible for deductibles and coinsurance amounts once they:
• Exhaust their upfront benefits or
• Receive a service not classified as an upfront benefit

For example, after members exhaust their upfront office visit benefit, any additional office visits do not require a copayment. However, members will be responsible for their deductible and coinsurance. After their deductible is met, coinsurance applies until the maximum coinsurance is met.

Embark claim example
Scenario:
An Embark member has four upfront office visits, copayment of $20 (Preferred), $250 deductible and 90/70/ 70 percent coinsurance level. The member visits a Preferred provider for a preventive visit. During the visit, the provider removes a suspicious mole. The member’s claims are paid as follows:

Benefit impact:

• Office visit: $20 copayment (three upfront office visits remaining)
• Mole removal (in-office surgery): Subject to $250 deductible and paid at 90 percent coinsurance
• Mole biopsy (sent to outside lab, may be billed on a separate claim): Charged against $400 outpatient radiology and laboratory benefit

Note: After upfront office visit limit is met, additional office visits (beginning with the fifth office visit in this scenario) are subject to deductible and coinsurance amounts. After upfront $400 outpatient radiology and laboratory benefit is met, any additional outpatient radiology and laboratory services are subject to deductible and coinsurance amounts.

Benefit summaries and additional product detail is available in the Products section.