20-21 / 88
20
21
Common
Medical Event
Services You May Need
Your cost if you use a
Limitations & Exceptions
Option 1
Option 2
Option 3
Participating Provider
Participating
Provider
Non-Participating
Provider
If you need drugs to
treat your illness or
condition
More information
about
prescription
drug coverage
is
available at
www.caremark.com
Generic drugs
Not covered
Not covered
Not covered
Prescription plan administered by
Caremark
Preferred brand drugs
Not covered
Not covered
Not covered
Prescription plan administered by
Caremark
Non-preferred brand drugs
Not covered
Not covered
Not covered
Prescription plan administered by
Caremark
Specialty drugs
Not covered
Not covered
Not covered
Specialty drugs are only provided by
Caremark Speciality Drug Services
1-800-237-2767
If you have outpatient
surgery
Facility fee (e.g., ambulatory surgery
center)
Non-Hospital:
5% coinsurance subject to
deductible
Hospital:
5% coinsurance subject to
deductible
Non-Hospital:
15% coinsurance subject
to deductible
Hospital:
15% coinsurance subject
to deductible
Non-Hospital:
30% coinsurance subject
to deductible
Hospital:
30% coinsurance subject
to deductible
–––––––––––none–––––––––––
Physician/surgeon fees
Non-Hospital:
$15 copay/PCP
$35 copay/Specialist
Hospital:
$15 copay/PCP
$35 copay/Specialist
Non-Hospital:
$50 copay
Hospital:
$50 copay
Non-Hospital:
30% coinsurance subject
to deductible
Hospital:
30% coinsurance subject
to deductible
–––––––––––none–––––––––––
If you need
immediate medical
attention
Emergency room services
$75 copay
$75 copay
$75 copay
Copay waived if admitted
Limited to Emergency Services or
unexpected, urgently required services;
Additional professional charges may apply
Emergency medical transportation
No member liability
No member liability
No copay, coinsurance
or deductible
Prior authorization is required for air
ambulance services, except for Medically
Necessary air ambulance services in an
emergency
Urgent care
$35 copay
$35 copay
$35 copay
Limited to unexpected, urgently required
services
If you have a hospital
stay
Facility fee (e.g., hospital room)
5% coinsurance subject to
deductible
15% coinsurance subject
to deductible
30% coinsurance subject
to deductible
Prior authorization is required
Physician/surgeon fee
5% coinsurance subject to
deductible
15% coinsurance subject
to deductible
30% coinsurance subject
to deductible
–––––––––––none–––––––––––
Common
Medical Event
Services You May Need
Your cost if you use a
Limitations & Exceptions
Option 1
Option 2
Option 3
Participating Provider
Participating
Provider
Non-Participating
Provider
If you have mental
health, behavioral
health, or substance
abuse needs
Mental/Behavioral health outpatient
services
Office Visits:
$15 copay
Office Visits:
$15 copay
Office Visits:
30% coinsurance subject
to deductible
For treatment at an Outpatient Hospital
Facility, an additional professional charge
may apply
Mental/Behavioral health inpatient
services
5% coinsurance subject to
deductible
15% coinsurance subject
to deductible
30% coinsurance subject
to deductible
Prior authorization is required; Additional
professional charges may apply
Requires authorization from Magellan 1-
800-245-7013
Substance use disorder outpatient
services
Office Visits:
$15 copay
Office Visits:
$15 copay
Office Visits:
30% coinsurance subject
to deductible
For treatment at an Outpatient Hospital
Facility, an additional professional charge
may apply
Substance use disorder inpatient
services
5% coinsurance subject to
deductible
15% coinsurance subject
to deductible
30% coinsurance subject
to deductible
Prior authorization is required; Additional
professional charges may apply
Requires authorization from Magellan 1-
800-245-7013
If you are pregnant
Prenatal and postnatal care
No member liability
No member liability
30% coinsurance subject
to deductible
For routine pre/postnatal office visits
only. For non-routine obstetrical care or
complications of pregnancy, cost sharing
may apply.
Delivery and all inpatient services
5% coinsurance subject to
deductible
5% coinsurance subject
to deductible
30% coinsurance subject
to deductible
Additional professional charges may apply