Coverage Summary
Is My Doctor In-Network?
| Benefit: | You Pay: |
|---|---|
| Primary Care Doctor Visit | $10 Copayment in-network |
| Specialist Visit | $45 Copayment in-network |
| Inpatient Hospital Care | $350 copay per day for days 1-4 in-network |
| Emergency Services (In and out-of-network) | $90 copay; ER copay waived if admitted |
| Urgent Care Services | $30 copay in and out-of-network |
Prescription Drug Coverage
| Benefit: | You Pay: |
|---|---|
| Prescription Drug Deductible | N/A |
| In-Network Prescription Drug Coverage - Initial Coverage | N/A |
| Coverage Gap | N/A |
| Catastrophic Coverage | N/A |
Extra Coverage
| Benefit: | |
|---|---|
| Extra Benefits | Routine Dental
|
Out of Network Coverage
| Benefit: | |
|---|---|
| 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 | N/A |