Coverage Summary
Is My Doctor In-Network?
| Benefit: | You Pay: |
|---|---|
|
Primary Care Doctor Visit
The Primary Care Doctor you choose will focus on your needs and coordinate your care with other network providers. |
$10 Copayment in-network |
|
Specialist Visit
Care you receive from a doctor who specializes in a certain type of medicine. Certain specialists do not require a Primary Care Doctor referral. Ask your Primary Care Doctor if you need a referral. |
$45 Copayment in-network |
|
Inpatient Hospital Care
Prior Authorization is required for non-emergency Inpatient Hospital stays. |
$350 copay per day for days 1-4 in-network |
|
Emergency Services (In and out-of-network)
Services received at a hospital facility's Emergency department, including both Professional and Facility services. |
$120 copay; ER copay waived if admitted |
|
Urgent Care Services
Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury or condition that requires immediate medical attention. |
$30 copay in and out-of-network |
Prescription Drug Coverage
| Benefit: | You Pay: |
|---|---|
|
Prescription Drug Deductible
The amount you must pay before our plan begins to pay its share of your covered drugs. |
N/A |
|
In-Network Prescription Drug Coverage - Initial Coverage
During the initial coverage stage, your plan helps cover the costs of your prescription drugs. How much you pay depends on which plan you have, what tier your prescription is in, and where and how you fill your prescription. Check your plan’s Evidence of Coverage for more details about what you pay. |
N/A |
|
Coverage Gap
In the coverage gap, you may pay more for your drugs than you did in the initial coverage stage. That’s why it’s called a “gap”. You stay in the coverage gap until your total out-of-pocket drug costs reach the Initial Coverage Limit. |
N/A |
|
Catastrophic Coverage
Once you reach the Catastrophic Stage, you pay a small copay and the plan will pay most of the cost of your drugs for the rest of the year. |
N/A |
Extra Coverage
| Benefit: | |
|---|---|
|
Extra Benefits
Enjoy some of these extra benefits included in your plan |
Routine Dental |
Out of Network Coverage
| Benefit: | |
|---|---|
|
Medical Services/Supplies
Medical Services/Supplies |
If you receive care from an out-of-network provider, your out-of-pocket costs will usually be higher than if you use a network provider. There are three exceptions: emergency care, urgently needed care and dialysis services. For details about the plan's coverage of out-of-network care, please refer to the Summary of Benefits or the Evidence of Coverage. (See "Plan Documents" below.) |
|
Prescription Drugs
Prescription Drugs |
N/A |