Primary Care Office Visit
$10
$10
Virtual Primary Care Visit
$10
$10
24 Hour Nursing Hotline
$0
$0
Specialist Office Visit
$30
$20
Diagnostic Tests & Procedures
$45
$45
Comprehensive Dental
(every 6 months)
Not covered
Dental PPO
10% of Cost - in -
network cleaning
10% of Cost - in
network x-rays
10% of Cost - in -
network exam
Eye Exams for Glasses
(every year)
Not covered
$25
Eyeglass Frames and Lenses
(every 2 years)
Not covered
$25
(Up to a maximum benefit of $150)
Acupuncture
Not covered
$10
(15 visits per year)
Transportation
$0
(24 one-way trips per year)
$0
(24 one-way trips per year)
Inpatient Hospital Care
$250 per day
(Days 1-6)
No charge for the
the remainder of your stay
$200 per day
(Days 1-6)
No charge for the
the remainder of your stay
Skilled Nursing Facility
$0
(Days 1-20)
$150
(Days 21-100)
$0
(Days 1-20)
$100
(Days 21-100)
Outpatient Surgery
$235
$200
Emergency Care
$75
($0 if admitted within 24 hours)
$75
($0 if admitted within 24 hours)
Worldwide Urgent or Emergency Care
Not covered
$75
Up to a maximum of $10,000
Urgent Care
$35
($0 if admitted within 24 hours)
$35
($0 if admitted within 24 hours)
These plans include Part D prescription drug coverage. The copayments below are for a one month supply of your prescription. Discounts are available for most prescriptions when when you use our mail order service for a three month supply.
Non-preferred Generics
$15
$15
Non-preferred Brand
$100
$100
Specialty
33% of Cost
33% of Cost
Coverage Gap Stage
Non-preferred Generics
$15
$15
Preferred Brand
40% of cost
40% of cost
Non-preferred Brand
51% of cost
51% of cost
Specialty
40% of cost
40% of cost
Catastrophic Coverage Stage
Generics
$3.30 or 5%
(Whichever is higher)
$3.30 or 5%
(Whichever is higher)
All Other Drugs
$8.25 or 5%
(Whichever is higher)
$8.25 or 5%
(Whichever is higher)