HMO SBCs & Plan Highlights_compressed

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

Services You May Need

Network Provider (You will pay the least)

Out-of-Network Provider (You will pay the most)

You may use live video visits at www.doctorondemand.com.

Primary care visit to treat an injury or illness

$30 co-pay /visit

Not Covered

If you visit a health care provider’s office or clinic

Preauthorization required for Sleep Studies, Neurofeedback & Transcranial Magnetic Stimulation (TMS) Preauthorization required for Genetic Testing and Immunizations for RSV.

$50 co-pay /visit

Not Covered

Specialist visit

Preventive care/screening/ immunization

No Charge

Not Covered

Preauthorization required for Genetic Testing. Copayment waived if performed at a designated laboratory/preferred center.

Diagnostic test (x-ray, blood work)

$50 co-pay /visit

Not Covered

If you have a test

Copayment waived if performed at a preferred center.

$50 co-pay /visit

Not Covered

Imaging (CT/PET scans, MRIs)

108308

SBC-Id :

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