HMO SBCs & Plan Highlights_compressed
What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information
Services You May Need
Network Provider (You will pay the least) Retail: $10 copay Mail-Order: $20 copay Deductible does not apply Retail: $30 copay Mail-Order: $60 copay Deductible does not apply Retail: $50 copay Mail-Order: $100 copay Deductible does not apply Retail: $10 copay /$30 copay /$50 copay Deduc tible does not apply
Out-of-Network Provider (You will pay the most)
Not Covered
Tier 1 drugs
Covers up to a 30-day supply (retail prescription)Íž 90 day supply (mail order prescription) Prescriptions must be written by a duly licensed health care provider and filled at a participating pharmacy, unless otherwise authorized in advance by CDPHP. Specialty drugs are not eligible for the mail order program and require preauthorization to be obtained through CDPHP's participating specialty vendors. This plan has Formulary 1 and the Premier Rx Network. You may have reduced cost share for preferred ambulatory surgery centers. Secure authorization before bariatric surgery or you may owe an additional 50% payment. All Emergency Care is considered In-Network. All Emergency Care is considered In-Network. Urgent Care from Non-Participating Urgent Care Centers in Our Service Area are not covered. You may use live video visits .
If you need drugs to treat your illness or condition More information about prescription drug coverage is available at http://www.cdphp.c om/Members/Rx- Corner
Not Covered
Tier 2 drugs
Not Covered
Tier 3 drugs
Not Covered
Specialty drugs
Facility fee (e.g., ambulatory surgery center)
$150 co-pay /visit
Not Covered
If you have outpatient surgery
No Charge
Not Covered
Physician/surgeon fees
$100 co-pay /visit
$100 co-pay /visit
Emergency room care
Emergency medical transportation
$100 co-pay /visit
$100 co-pay /visit
If you need immediate medical attention
$35 co-pay /visit
$35 co-pay /visit
Urgent care
$1,000 co-pay /visit
Not Covered
None.
Facility fee (e.g., hospital room)
If you have a hospital stay
Secure authorization before bariatric surgery or you may owe an additional 50% payment.
No Charge
Not Covered
Physician/surgeon fees
108308
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