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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