@knnrn
In-network limit 8000 USD
Out of Network limit 2700 USD
In-Network Scale (Out of Network -No covered )
Outpatient Hospital İn network %25 Member pay-per visit
Physician Service 0 USD Co payment-per visit
Independent clinic lab 0 USD Co-payment
Diagnostic Services (x-ray , bone density, etc) 6 USD Co-payment
Advanced Imaging Services (AIS) -Incld MRI, MRA, PET, CT & Nuclear medicine %25 Member pay
Urgent Care Center
Urgent care provider First 2 visits 0 USD All others 10 USD
In-network 10 USD
Emergency Room
In-network 200 USD Co-payment
Out of Network 200 USD Co-payment
Physician Services at ER
In-network 0 USD
Ambulance
In-network Member pays %25
Ambulatory Surgical Centre
In-network Member pays %25
Inpatient Hospital Services
In-network Member pays %25
Outpatient Hospital Services
In-network Member pays %25
Emergency Room Services
In-network 200 USD Co-payment
Out of Network 200 USD Co-payment
Family Physician visits (In-network)
0 USD For 3 visit 4 USD Co-pay for all other visits
Specialist (In-Network)
10 USD Co-payment
Retail Prescription Drugs
Level 1 0 USD
Level 2 2 USD
Level 3 3 USD
Level 4 11 USD
Level 5 22 USD
Level 6 50%
Medical Pharmacy Benefit
In-network 30 USD Co-payment Low Tier
60 USD Co-payment STD