Preferred / Non-preferred

You pay $75 / $150 copay

Ambulatory Surgery

You pay $75 copay

Illness

You pay $15 copay

Accident

You pay $15 copay

Generalists

You pay $10 copay

Specialists

You pay $15 copay

Sub-specialist

You pay $15 copay

Accident

You pay $25 copay

Sickness

You pay $75 copay

Imaging

You pay 25%

Lab

You pay 25% (inside selective network) / 40% (outside selective network)

X-rays

You pay 25%

Outpatient Services

You pay $15 copay

Inpatient Services – admission

You pay $75 copay (inside selective network) / $150 (outside selective network)

Inpatient Services – partial admission

You pay $25 copay (inside selective network) / $50 (outside selective network)

Bioequivalent

You pay $3 copay

Brand & Specialty

• Level 1 ($0 – $1,200): You pay 20%, minimum $20
• Level 2 ($1,201 – $3,000): You pay 25%, minimum $30
• Level 3 ($3,001+): You pay 30%, minimum $40

Bioequivalent

You pay $6 copay

Brand

• Level 1 ($0 – $1,200): You pay 15%, minimum $40
• Level 2 ($1,201 – $3,000): You pay 19%, minimum $60
• Level 3 ($3,001+): You pay 23%, minimum $80

Plan Details

You pay 25% for exams