What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information
Services You May Need
In-Network Provider (You will pay the least) 40% coinsurance but not less than $50 or more than $100/prescription (retail 30 days), 40% coinsurance but not less than $100 or more than $200/prescription (retail 90 days); 40% coinsurance but not less than $100 or more than $200/prescription (home delivery 90 days) Deductible does not apply 50% coinsurance but not less than $75 or more than $150/prescription (retail); 50% coinsurance but not less than $75 or more than $150/prescription (home delivery 30 days) Deductible does not apply
Out-of-Network Provider (You will pay the most)
50% coinsurance/prescription (retail); Not covered (home delivery) Deductible does not apply
Non-preferred brand drugs (Tier 3)
50% coinsurance/prescription (retail); Not covered (home delivery) Deductible does not apply
Specialty drugs (Tier 4)
Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees
20% coinsurance 20% coinsurance
50% coinsurance 50% coinsurance
None None
If you have outpatient surgery
Out-of-network services are paid at the in-network cost share and deductible. Out-of-network air ambulance services are paid at the in-network cost share and deductible.
Emergency room care
20% coinsurance
20% coinsurance
If you need immediate medical attention
Emergency medical transportation
No charge Deductible does not apply $50 copay/visit Deductible does not apply
No charge Deductible does not apply $50 copay/visit Deductible does not apply
Urgent care
None
Facility fee (e.g., hospital room) Physician/surgeon fees
20% coinsurance 20% coinsurance
50% coinsurance 50% coinsurance
None None
If you have a hospital stay
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