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) retail or MCN or mail order) Paid the same as generic, preferred and non- preferred drugs (retail)
specialty pharmacy network. Certain specialty drugs are eligible for copay assistance programs through CVS True Accumulation Program. Preauthorization required for certain surgeries. If you don't get preauthorization, non-participating provider benefits could be reduced by 50% of the total cost of the service. See your plan document for a detailed listing. Non-participating providers paid at the participating provider level of benefits. Copay is waived if admitted to the hospital. Non-participating providers paid at the participating provider level of benefits for emergency services for ground & air ambulance and non-emergency services for air ambulance.
Specialty drugs
Not Covered
If you have outpatient surgery
Facility fee (e.g., ambulatory surgery center)
20% coinsurance
50% coinsurance
Physician/surgeon fees
20% coinsurance
50% coinsurance
If you need immediate medical attention
Emergency room care
$300 copay/visit, then 20% coinsurance
$300 copay/visit, then 20% coinsurance
Emergency medical transportation
20% coinsurance (emergency & non- emergency services- ground & air)
20% coinsurance (emergency services – ground & air)/ 20% coinsurance (non- emergency services - air)/50% coinsurance (non- emergency services – ground)
Urgent care
$25 copay/visit (office visit)/20% coinsurance (all other services)
50% coinsurance
Copay applies to the physician office visit only.
If you have a hospital stay
Facility fee (e.g., hospital room) Physician/surgeon fees
20% coinsurance
50% coinsurance
Preauthorization required. If you don't get preauthorization, non-participating providers benefits could be reduced by 50% of the total cost of the service.
20% coinsurance
50% coinsurance
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