Specialty drugs Applicable cost as Not covered None ––––––––––– ––––––––––– noted above for generic or brand drugs. Your Cost If Your Cost Common You Use a If You Use Services You May Need Limitations & Exceptions Medical Event Network an Provider Facility fee (e.g., ambulatory Preferred Network 40% coinsurance after None ––––––––––– ––––––––––– Provider surgery center) Facility 10% calendar year deductible coinsurance, after deductible. All others If you have 20% coinsurance, after outpatient surgery deductible; Non-free standing hospital: 5% coinsurance, after deductible None Physician/surgeon fees Preferred Network 40% coinsurance after ––––––––––– ––––––––––– 10% coinsurance, after calendar year deductible deductible. All others 20% coinsurance, after deductible. Emergency room services $300 copay per visit $300 copay per visit None If you need ––––––––––– ––––––––––– immediate Emergency medical transportation 0% coinsurance 0% coinsurance None ––––––––––– ––––––––––– medical attention Urgent care $25 per visit 40% coinsurance after None ––––––––––– ––––––––––– calendar year deductible
Specialty drugs Applicable cost as noted above for generic or brand drugs. Not covered ––––––––––– None ––––––––––– Common Medical Event Services You May Need Your Cost If You Use a Network Provider Your Cost If You Use an Provider Limitations & Exceptions If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) Preferred Network Facility 10% coinsurance, after deductible. All others 20% coinsurance, after deductible; Non-free standing hospital: 5% coinsurance, after deductible 40% coinsurance after calendar year deductible ––––––––––– None ––––––––––– Physician/surgeon fees Preferred Network 10% coinsurance, after deductible. All others 20% coinsurance, after deductible. 40% coinsurance after calendar year deductible ––––––––––– None ––––––––––– If you need immediate medical attention Emergency room services $300 copay per visit $300 copay per visit ––––––––––– None ––––––––––– Emergency medical transportation 0% coinsurance 0% coinsurance ––––––––––– None ––––––––––– Urgent care $25 per visit 40% coinsurance after calendar year deductible ––––––––––– None –––––––––––