Copayments

You are responsible for certain copayment expenses each time certain covered medical expenses are incurred. Each individual covered under the plan has his or her own copayments. Copayments do not apply toward the $200 annual deductible or $2,300 annual coinsurance maximum.

$50 Emergency Room Copayment

You are responsible for the first $50 of covered expenses for each emergency room visit. If you are admitted as an inpatient directly following treatment in the emergency room, the $50 copayment is waived.

$10 Office Visit Copayment

You are responsible for the first $10 of covered expenses when a physician or mental health care provider bills an office visit. This $10 copayment does not apply toward the $200 annual deductible or $2,300 annual coinsurance maximum. Chiropractors, physical, speech and occupational therapists, and chemical dependency counselors are not subject to this office visit copayment.

$10 Nonpreferred Provider Office Visit Copayment

You are responsible for an additional $10 of covered expenses when a nonpreferred provider bills an office visit. This $10 copayment does not apply toward the $200 annual deductible or $2,300 annual coinsurance maximum. Care received outside the preferred provider network is not subject to this office visit copayment.

$200 Nonpreferred Inpatient Hospital Copayment

You are responsible for the first $200 of covered expenses for inpatient hospital admissions at a nonpreferred provider facility. This $200 copayment does not apply toward the $200 annual deductible or $2,300 annual coinsurance maximum. Inpatient hospital admissions received outside the preferred provider network are not subject to this copayment.

Prescription Copayments

Medco Health Retail Pharmacy Program

• $7 copayment for each generic prescription.
• $15 copayment for each brand-name prescription listed on the drug program formulary.
• $30 copayment for each brand-name prescription not listed on the drug program formulary.

Medco By Mail

• $14 copayment for each generic prescription.
• $30 copayment for each brand-name prescription listed on the drug program formulary.
• $60 copayment for each brand-name prescription drug not listed on the drug program formulary.