What You Will Pay
Tier III (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
Tier I Provider -All Hughston entities (You will pay the least)
Common Medical Event
Services You May Need
Limitations, Exceptions, & Other Important Information
Tier II (Network) Provider
$50 copay/visit, deductible does not apply
$50 copay/visit, deductible does not apply
Copay applies to exam charge only. Does not include office surgery. See Plan Document for other services. Routine labs and x-rays are covered for out-of-network providers at no charge. You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Does not include emergency room or urgent care diagnostic services. 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). Rx Deductible applies to Tier II, Tier III, and specialty medications only. 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
Specialist visit
40% coinsurance
Preventive care/screening/ immunization
No charge, deductible does not apply
No charge, deductible does not apply
40% coinsurance
No charge, deductible does not apply
No charge, deductible does not apply
Diagnostic test (x- ray, blood work) Imaging (CT/PET scans, MRIs) Generic drugs (Tier 1) Preferred brand drugs (Tier 2) Non-preferred brand drugs (Tier 3)
No charge, deductible does not apply
If you have a test
20% coinsurance
20% coinsurance 40% coinsurance
$10 copay/prescription (retail) $20 copay/prescription (extended retail and mail-order)
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.proactrx.com
$30 copay/prescription (retail) $60 copay/prescription (extended retail and mail-order)
$60 copay/prescription (retail) $120 copay/prescription (extended retail and mail-order) Please contact Noble Specialty Pharmacy 888-843-2040 Web: www.noblehealthservices.com $120 copay per prescription
Specialty drugs (Tier 4)
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