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 be limited to 175% of the Medicare fee schedule
Limitations, Exceptions, & Other Important Information
Common Medical Event
Services You May Need
Network Provider (You will pay the least)
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.
$10 copay/prescription (retail) $20 copay/prescription (extended retail and mail-order)
Generic drugs (Tier 1)
$30 copay/prescription (retail) $60 copay/prescription (extended retail and mail-order)
Preferred brand drugs (Tier 2)
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.proactrx.com
$60 copay/prescription (retail) $120 copay/prescription (extended retail and mail-order)
Non-preferred brand drugs (Tier 3)
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)
0% coinsurance
40% coinsurance
Pre-notification is recommended.
If you have outpatient surgery
Physician/surgeon fees
0% coinsurance
40% coinsurance
None
Emergency room care
0% coinsurance
0% coinsurance
None
Pre-notification is recommended for elective (non-emergent) transportation by ambulance or medical van, and all transfers via air ambulance.
Emergency medical transportation
If you need immediate medical attention
0% coinsurance
0% coinsurance
Urgent care
0% coinsurance
40% coinsurance
None
Facility fee (e.g., hospital room)
If you have a hospital stay
0% coinsurance
40% coinsurance
Pre-notification is recommended.
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