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) 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) 20% coinsurance
50% coinsurance 50% coinsurance 20% coinsurance $50 copay/visit 50% coinsurance 50% coinsurance No charge
50% penalty for no precertification. 50% penalty for no precertification.
If you have outpatient surgery
Physician/surgeon fees Emergency room care Emergency medical transportation Facility fee (e.g., hospital room) Physician/surgeon fees Urgent care
20% coinsurance 20% coinsurance
None None None
If you need immediate medical attention
No charge
$50 copay/visit 20% coinsurance 20% coinsurance
50% penalty for no precertification. 50% penalty for no precertification.
If you have a hospital stay
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