Coverage Summary
|
Is My Doctor In-Network? Is My Doctor In-Network? |
|
|---|---|
|
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
|
Prescription Drug Deductible |
N/A |
|---|---|
|
In-Network Prescription Drug Coverage - Initial Coverage |
N/A |
|
Coverage Gap |
N/A |
|
Catastrophic Coverage |
N/A |
Extra Coverage
|
Extra Benefits |
Routine Dental
|
|---|
Out of Network Coverage
|
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 |
Plan Documents
| Summary of Benefits (PDF) |
|
|---|---|
| Evidence of Coverage (PDF) |
|
| Plan Rating (PDF) |
|
| General Transition Notice (PDF) |
|
| Low Income Subsidy Premium Summary Table for Those Receiving Extra Help (PDF) |
|
| Comprehensive Formulary (PDF) |
|
| Service Area Map | |
| Annual Notice of Change |
|
| Enrollment Forms |
|