All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
If you visit a health care provider’s office or clinic
Service Type | In-Network Cost | Out-of-Network Cost | Details and Exceptions |
|---|---|---|---|
Primary Care Visit | $25 copayment, no deductible required | 40% coinsurance | Telehealth visits: $10 copayment |
Specialist Visit | 20% coinsurance | 40% coinsurance | |
Preventive Care/Screening/Immunization | No charge, no deductible required | Not covered | Confirm with your provider if needed services are covered. |
If you have a test
Service Type | In-Network Cost | Out-of-Network Cost | Details and Exceptions |
|---|---|---|---|
Diagnostic Test (X-ray, Blood Work) | 20% coinsurance | 40% coinsurance | |
Imaging (CT/PET scans, MRIs) | 20% coinsurance | 40% coinsurance |
If you need drugs to treat your illness or condition, or information about prescription drug coverage.
Services You May Need | In-Network Provider Cost | Out-of-Network Provider Cost | Limitations and Other Information |
|---|---|---|---|
Preferred Generic Drugs | Retail: $12 copay; Mail order: $24 copay | You pay 100% then request reimbursement of the in-network amount, less the applicable deductible or copay. | No charge for certain FDA-approved generics; mail order allows 60-90-day supply. Approval needed for some prescriptions |
Non-Preferred Generic Drugs | Retail: $30 copay; Mail order: $60 copay | You pay 100% then request reimbursement of the in-network amount, less the applicable deductible or copay. | |
Preferred Brand Drugs | Retail: $45 copay; Mail order: $90 copay | You pay 100% then request reimbursement of the in-network amount, less the applicable deductible or copay. | |
Non-Preferred Brand Drugs | Retail: $100 copay; Mail order: $200 copay | You pay 100% then request reimbursement of the in-network amount, less the applicable deductible or copay. | |
Specialty Drugs | Retail: $100 copay | Not covered |
If you have outpatient surgery
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
If you visit a health care provider’s office or clinic
Service Type | In-Network Cost | Out-of-Network Cost | Details and Exceptions |
|---|---|---|---|
Primary Care Visit | $25 copayment, no deductible required | 40% coinsurance | Telehealth visits: $10 copayment |
Specialist Visit | 20% coinsurance | 40% coinsurance | |
Preventive Care/Screening/Immunization | No charge, no deductible required | Not covered | Confirm with your provider if needed services are covered. |
If you have a test
Service Type | In-Network Cost | Out-of-Network Cost | Details and Exceptions |
|---|---|---|---|
Diagnostic Test (X-ray, Blood Work) | 20% coinsurance | 40% coinsurance | |
Imaging (CT/PET scans, MRIs) | 20% coinsurance | 40% coinsurance |
If you need drugs to treat your illness or condition, or information about prescription drug coverage.
Services You May Need | In-Network Provider Cost | Out-of-Network Provider Cost | Limitations and Other Information |
|---|---|---|---|
Preferred Generic Drugs | Retail: $12 copay; Mail order: $24 copay | You pay 100% then request reimbursement of the in-network amount, less the applicable deductible or copay. | No charge for certain FDA-approved generics; mail order allows 60-90-day supply. Approval needed for some prescriptions |
Non-Preferred Generic Drugs | Retail: $30 copay; Mail order: $60 copay | You pay 100% then request reimbursement of the in-network amount, less the applicable deductible or copay. | |
Preferred Brand Drugs | Retail: $45 copay; Mail order: $90 copay | You pay 100% then request reimbursement of the in-network amount, less the applicable deductible or copay. | |
Non-Preferred Brand Drugs | Retail: $100 copay; Mail order: $200 copay | You pay 100% then request reimbursement of the in-network amount, less the applicable deductible or copay. | |
Specialty Drugs | Retail: $100 copay | Not covered |
If you need surgery
Services You May Need | In-Network Provider (You will pay the least) | Out-of-Network Provider (You will pay the most) | Limitations, Exceptions and Other Important Information |
|---|---|---|---|
Facility fee (e.g., ambulatory surgery center) | 20% coinsurance | 40% coinsurance | |
Provider/surgeon fees | 20% coinsurance | 40% coinsurance |
If you need immediate medical attention
Services You May Need | In-Network Provider (You will pay the least) | Out-of-Network Provider (You will pay the most) | Limitations, Exceptions and Other Important Information |
|---|---|---|---|
Emergency room care | $50 copay/1st visit; $200 copay/each additional visit plus 20% coinsurance | $50 copay/1st visit; $200 copay/each additional visit plus 20% coinsurance | Copayment waived if admitted |
Emergency medical transportation | 20% coinsurance | 40% coinsurance | |
Urgent care | 20% coinsurance | 40% coinsurance |