What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information
Services You May Need
In-Network Provider (You will pay the least) 50% coinsurance but not less than $80 or more than $160/prescription (retail); 50% coinsurance but not less than $80 or more than $160/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
Specialty drugs (Tier 4)
Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees
50% penalty for no out-of-network precertification. 50% penalty for no out-of-network precertification. 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.
20% coinsurance
50% coinsurance
If you have outpatient surgery
20% coinsurance
50% coinsurance
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
50% penalty for no out-of-network precertification. 50% penalty for no out-of-network precertification. 50% penalty if no precert of out-of- network non-routine services (i.e., partial hospitalization, etc.). Includes medical services for MH/SA diagnoses. 50% penalty for no out-of-network precertification. Includes medical services for MH/SA diagnoses. Primary Care or Specialist benefit
20% coinsurance
50% coinsurance
If you have a hospital stay
20% coinsurance
50% coinsurance
$30 copay/office visit** $20 copay/MDLIVE visit** 20% coinsurance/all other services **Deductible does not apply
50% coinsurance/office visit 50% coinsurance/all other services
Outpatient services
If you need mental health, behavioral health, or substance abuse services
Inpatient services
20% coinsurance
50% coinsurance
If you are pregnant
Office visits
20% coinsurance
50% coinsurance
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