| Common Medical Event | Services You May Need | What You Will Pay | Limitations, Exceptions, & Other Important Information | |
|---|---|---|---|---|
|
Network Provider
(You will pay the least)
|
Non-Network Provider
(You will pay the most)
|
|||
|
If you need drugs to treat your illness or condition
More information about prescription drug coverage is available at MedMutual.com/SBC
|
Generic copay - retail Tier 1 | $10 after deductible | See Plan Documents for Details | Covers up to a 30-day supply. |
| Generic copay - home delivery Tier 1 | $25 after deductible | See Plan Documents for Details | Covers up to a 90-day supply. | |
| Preferred brand copay - retail Tier 2 | $35 after deductible | See Plan Documents for Details | Covers up to a 30-day supply. | |
| Preferred brand copay - home delivery Tier 2 | $87.50 after deductible | See Plan Documents for Details | Covers up to a 90-day supply. | |
| Non-preferred brand copay - retail Tier 3 | $60 after deductible | See Plan Documents for Details | Covers up to a 30-day supply. | |
| Non-preferred brand copay - home delivery Tier 3 | $150 after deductible | See Plan Documents for Details | Covers up to a 90-day supply. | |
| Specialty drugs | $200 after deductible | See Plan Documents for Details | Covers up to a 30-day supply. | |
| If you have outpatient surgery | Facility fee (e.g., ambulatory surgery center) | No charge after deductible | 50% coinsurance | None |
| Physician/surgeon fees (Outpatient) | No charge after deductible | 50% coinsurance | None | |
| If you need immediate medical attention | Emergency room care | No charge after deductible | None | |
| Emergency medical transportation | No charge after deductible | 50% coinsurance | None | |
| Urgent care | No charge after deductible | 50% coinsurance | None | |
| If you have a hospital stay | Facility fee (e.g., hospital room) | No charge after deductible | 50% coinsurance | None |
| Physician/ surgeon fee (inpatient) | No charge after deductible | 50% coinsurance | None | |
| If you need mental health, behavioral health, or substance abuse services | Outpatient services | Benefits paid based on corresponding medical benefits | None | |
| Inpatient services | Benefits paid based on corresponding medical benefits | None | ||