Specialist 40%(5) Coinsurance $35(2,3) Co-pay per $45(1,2,3) Co-pay per visit visit Diabetes supplies (6) (If purchased 40%(5) Coinsurance through a Durable Medical Equipment Provider). Other Diabetic Supplies are 10%(3,4,6) 30%(1,3,4,6) covered under the Express Scripts Coinsurance Coinsurance Prescription Drug Benefit. PRESCRIPTION DRUGS(2,3) Administered by Express Scripts. Call Express Scripts at 1-800-232-6549. MENTAL HEALTH SERVICES Outpatient $35(2,3) Co-pay per $45(1,2,3) Co-pay per 40%(5) Coinsurance visit visit Inpatient/Partial Hospitalization (6) 10%(3,4,6) 30%(1,3,4,6) 40%(5) Coinsurance Coinsurance Coinsurance ALCOHOL AND SUBSTANCE ABUSE SERVICES Rehabilitation Outpatient $35(2,3) Co-pay per $45(1,2,3) Co-pay per 40%(5) Coinsurance visit visit Inpatient/Partial Hospitalization (6) 10%(3,4,6) 30%(1,3,4,6) 40%(5,6) Coinsurance Coinsurance Coinsurance Detoxification Outpatient $35(2,3) Co-pay per $45(1,2,3) Co-pay per 40%(5,6) Coinsurance visit visit Inpatient/Partial Hospitalization (6) 10%(3,4,6) 30%(1,3,4,6) 40%(5,6) Coinsurance Coinsurance Coinsurance
Specialist Diabetes supplies (6) (If purchased through a Durable Medical Equipment Provider). Other Diabetic Supplies are covered under the Express Scripts Prescription Drug Benefit. $35(2,3) Co-pay per visit 10%(3,4,6) Coinsurance $45(1,2,3) Co-pay per visit 30%(1,3,4,6) Coinsurance 40%(5) Coinsurance 40%(5) Coinsurance PRESCRIPTION DRUGS(2,3) Administered by Express Scripts. Call Express Scripts at 1-800-232-6549. MENTAL HEALTH SERVICES Outpatient $35(2,3) Co-pay per visit $45(1,2,3) Co-pay per visit 40%(5) Coinsurance Inpatient/Partial Hospitalization (6) 10%(3,4,6) Coinsurance 30%(1,3,4,6) Coinsurance 40%(5) Coinsurance ALCOHOL AND SUBSTANCE ABUSE SERVICES Rehabilitation Outpatient $35(2,3) Co-pay per visit $45(1,2,3) Co-pay per visit 40%(5) Coinsurance Inpatient/Partial Hospitalization (6) 10%(3,4,6) Coinsurance 30%(1,3,4,6) Coinsurance 40%(5,6) Coinsurance Detoxification Outpatient $35(2,3) Co-pay per visit $45(1,2,3) Co-pay per visit 40%(5,6) Coinsurance Inpatient/Partial Hospitalization (6) 10%(3,4,6) Coinsurance 30%(1,3,4,6) Coinsurance 40%(5,6) Coinsurance
Provider-Resource-Guide-2017-2018.docx