All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information
Non-Participating Provider (You will pay the most)
Services You May Need
Participating Provider (You will pay the least)
If you visit a health care provider’s office or clinic
Primary care visit to treat an injury or illness
20% coinsurance
50% coinsurance
Includes telemedicine. There is no charge after the deductible for services received at a MinuteClinic. You may have to pay for services that aren’t preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. Lab services limited to 18 presumptive drug tests and 18 definitive drug tests per year. Preauthorization required for PET scans and non- orthopedic CT/MRI’s. If you don't get preauthorization, non- participating provider benefits could be reduced by 50% of the total cost of the service. Major medical deductible applies. Covers up to a 90-day supply (retail prescription); 90-day supply (Maintenance Choice Network (MCN) or mail order prescription); 30-day supply (specialty drugs). There is no charge for preventive drugs. Dispense as Written (DAW) provision applies. Specialty drugs must be obtained from the specialty pharmacy network. Certain specialty drugs are eligible for copay assistance programs through CVS True Accumulation Program.
Specialist visit
20% coinsurance
50% coinsurance 50% coinsurance
Preventive care/screening/ immunization
No Charge
If you have a test
Diagnostic test (x-ray, blood work)
20% coinsurance
50% coinsurance
Imaging (CT/PET scans, MRIs)
20% coinsurance
50% coinsurance
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.caremark.com
Generic drugs
20% coinsurance (retail & MCN or mail order) 20% coinsurance(retail & MCN or mail order)
Not Covered
Preferred brand drugs
Not Covered
Non-preferred brand drugs 20% coinsurance(retail & MCN or mail order)
Not Covered
Specialty drugs
20% coinsurance
Not Covered
2 of 7
Made with FlippingBook Digital Publishing Software