What You Will Pay
Out-of-Network Provider (You will pay the most)
Payment of all Out-Of-Network professional services will be limited to 135% of the Medicare fee schedule. Payment of all Out- Of-Network facility services will
Common Medical Event
Limitations, Exceptions, & Other Important Information
Network Provider (You will pay the least)
Services You May Need
be limited to 175% of the Medicare fee schedule
Imaging (CT/PET scans, MRIs)
Does not include urgent care imaging services. Covers up to a 30-day supply (retail prescription); 90-day supply (extended retail and mail order prescription). Deductible applies. Once the out-of- pocket maximum has been met, prescription drugs shall be covered at 100% for the remainder of the calendar year. Mail order is only available through Proact Pharmacy Services. Please contact ProAct 866 – 287 – 9885 Web:www.ProActPharmacyServices.com* See Plan Document for non-use of generic drug penalty. Pre-notification is recommended for certain surgeries.
20% coinsurance
40% coinsurance
$10 copay/prescription (retail) $20 copay/prescription (extended retail and mail-order) $30 copay/prescription (retail) $60 copay/prescription (extended retail and mail-order) $60 copay/prescription (retail) $120 copay/prescription (extended retail and mail-order)
Generic drugs (Tier 1)
Preferred brand drugs (Tier 2) Non-preferred brand drugs (Tier 3)
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.proactrx.com
Please contact Noble Specialty Pharmacy 888-843-2040 Web: www.noblehealthservices.com $120 copay per prescription
Specialty drugs (Tier 4)
Facility fee (e.g., ambulatory surgery center)
20% coinsurance
40% coinsurance
If you have outpatient surgery
Physician/surgeon fees
20% coinsurance
40% coinsurance
None
Emergency room care
20% coinsurance
None.
Pre-notification is recommended for elective (non-emergent) transportation by ambulance or medical van, and all transfers via air ambulance.
If you need immediate medical attention
Emergency medical transportation
20% coinsurance
20% coinsurance
Urgent care
20% coinsurance
40% coinsurance
None
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