What is the overall deductible?
What is the out-of-pocket limit for this plan?
Do you need a referral to see a specialist?
Common Medical Events
Primary care visit to treat an injury or an illness: $10.00 Copayment per visit
Specialist visit: $15.00 Copayment per visit
Preventive care/screening/immunization: NO CHARGE
Diagnostic test (x-ray, blood work): NO CHARGE for Office, Independent, Laboratory, Outpatient Hospital
Imaging (CT/PET scans, MRIs): $100.00 Copayment per visit for Network Outpatient Facility and in a Network Doctor’s Office
If you need drugs to treat your illness or condition – Tier 1 Provider
Generic Drugs: $10.00 Copayment/Retail
Preferred Brand Drugs: $25.00 Copayment/Retail
Non-preferred brand drugs: $50.00 Copayment/Retail
If you have outpatient surgery
Facility fee (e.g., ambulatory surgery center): $150.00 Copayment per visit for Ambulatory Surgical Center, Outpatient Hospital
Physician/surgeon fees: No charge for Ambulatory Surgical Center, Outpatient Hospital
If you need medical attention
Emergency room care: $100 Copayment per visit for Outpatient Hospital
Emergency medical transportation: NO CHARGE
Urgent Care: $40.00 Copayment
If you have a hospital stay
Facility Fee (e.g., hospital room): $250
If you need mental health, behavioral health, or substance abuse services – Tier 1 Provider
Outpatient Services: $15.00 Copayment
(Subject to change at plan renewal time WITHOUT notice and currently, the Malachy Family pays 80% of this Platinum Plan by Cigna!)
