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Copayment Maximum of $200 for
25% coinsurance / up to a 30 day supply of an orally
prescription retail administered anticancer
up to a $250 medication regardless of a
copay max per Prescription Drug Deductible
Tier 4 Specialty prescription 25% Not covered and/or Medical Deductible. You
drugs coinsurance / may be required to use a lower-
prescription mail order cost drug(s) prior to benefits under
up to a your policy being available for
$500 copay max per certain prescribed drugs. See the
prescription website listed for information on
drugs covered by your plan.
Facility fee (e.g.,
ambulatory surgery $500 copay / admit Not covered
If you have outpatient center) None
surgery
Physician/surgeon No charge Not covered
fees
Emergency room $500 copay / visit $500 copay / visit Copayment waived if admitted.
care
Emergency medical
If you need immediate transportation $100 copay / trip $100 copay / trip None
medical attention
If you receive services in addition to
Urgent care $30 copay / visit $75 copay / visit urgent care, additional copayments
or coinsurance may apply.
Facility fee (e.g., Copayment applies to a maximum
If you have a hospital hospital room) $1,000 copay / day Not covered of 4 days per stay.
stay Physician/surgeon No charge Not covered None
fees

Common What You Will Pay Limitations, Exceptions, & Other
Medical Event Services You May Participating Provider Non-Participating Important
Need (You will pay the Provider (You will pay Information
least) the most)

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