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) Office visits: No Charge (under age 19)/$15 copay/visit (age 19 & over)/20% coinsurance (all other services) $50 copay/visit (office visit)/ 2% coinsurance (all other services)
If you visit a health care provider’s office or clinic
Primary care visit to treat an injury or illness
50% coinsurance
Copay applies to the physician office visit only. Includes telemedicine. There is no charge and the deductible does not apply for services received at a MinuteClinic.
Specialist visit
50% coinsurance
Preventive care/screening/ immunization
No Charge
50% coinsurance
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. Deductible does not apply. 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). The copay applies per prescription. There is no charge for preventive drugs. Dispense as Written (DAW) provision applies. Specialty drugs must be obtained from the
If you have a test
Diagnostic test (x-ray, blood work)
20% coinsurance
50% coinsurance
Imaging (CT/PET scans, MRIs)
$500 copay/visit, then 50% coinsurance
$500 copay/visit, then 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 copay (30-day retail)/$50 copay (90-day retail or MCN or mail order) $45 copay (30-day retail)/$112.50 copay (90- day retail or MCN or mail order)
Not Covered
Preferred brand drugs
Not Covered
Non-preferred brand drugs $80 copay (30-day
Not Covered
retail)/$200 copay (90-day
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