Network Health Forward co-payments
Use this chart to find services and co-payments by Plan Type for Network Health Forward®, our
Commonwealth Care plan:
Service
|
Co-payment
|
|
Commonwealth Care
Plan Type I
|
Commonwealth Care
Plan Type II
|
Commonwealth Care
Plan Type III
|
Outpatient Medical Care
(Hospital or clinic treatment that does not require an overnight stay)
|
Community health center visits
|
No co-payment (PCP/specialty)
|
$10-$18 co-payment (PCP/specialty)
|
$15-$22 co-payment (PCP/specialty)
|
Office visits
|
No co-payment (PCP/specialty)
|
$10-$18 co-payment (PCP/specialty)
|
$15-$22 co-payment(PCP/specialty)
|
Outpatient surgery (hospital/ ambulatory surgery centers)
|
No co-payment
|
$50 co-payment
|
$125 co-payment
|
X-rays/labs
|
No co-payment
|
No co-payment
|
No co-payment
|
Abortion services
|
No co-payment
|
$50 co-payment
|
$100 co-payment
|
Inpatient Medical Care
(Hospital or clinic treatment that requires at least one overnight stay)
|
Room and board (includes deliveries/surgery/
X-rays/labs)
|
No co-payment
|
$50 co-payment
|
$250 co-payment
|
Prescription Drugs
|
Medication via pharmacy (1-month supply)
|
$1 - $3.65
co-payment
|
$10/$20/$40 co-payment (generic/ preferred/ nonpreferred)
|
$12.50/$25/$50 co-payment (generic/ preferred/ nonpreferred)
|
Medication via mail (3-month supply)
|
N/A
|
$20/$40/$120 co-payment (generic/ preferred/ nonpreferred)
|
$25/$50/$150 co-payment (generic/ preferred/ nonpreferred)
|
Emergency Care
|
Emergency care
|
No co-payment
|
$50 co-payment
|
$100 co-payment
|
Inpatient Mental Health and Substance Abuse
(Hospital or clinic treatment that requires at least one overnight stay)
|
Inpatient mental health and substance abuse services
|
No co-payment
|
$50 co-payment
|
$250 co-payment
|
Outpatient Mental Health and Substance Abuse
(Hospital or clinic treatment that does not require an overnight stay)
|
Outpatient mental health and substance abuse services
|
No co-payment
|
$10 co-payment
|
$15 co-payment
|
Methadone-related services
|
No co-payment
|
No co-payment
|
No co-payment
|
Rehabilitation Services
|
Cardiac rehabilitation
|
No co-payment
|
No co-payment
|
No co-payment
|
Home health care
|
No co-payment
|
No co-payment
|
No co-payment
|
Extended inpatient care (100 total days per benefit year):
|
|
|
No co-payment
|
No co-payment
|
No co-payment
|
|
|
No co-payment
|
$50 co-payment
|
$250 co-payment
|
Short-term outpatient rehab
(physical, occupational, and speech therapies)
|
No co-payment
|
$10 co-payment
|
$20 co-payment
|
Other Benefits
|
Ambulance
|
No co-payment
|
No co-payment
|
No co-payment
|
Dental
[preventive/radiography/diagnostic (exams and X-rays) /extractions/emergency care/oral surgery]
|
No co-payment
|
N/A
|
N/A
|
DME supplies/prosthetics/oxygen and respiratory therapy equipment
|
No co-payment
|
No co-payment
|
10% of cost
|
Hospice
|
No co-payment
|
No co-payment
|
No co-payment
|
Routine vision (exam and glasses every 24 months)
|
No co-payment
|
$10 co-payment
|
$20 co-payment
|
Wellness (family planning/nutrition)
|
No co-payment
|
No co-payment
|
No co-payment
|
Maximum Yearly Out-Of-Pocket Expenses
|
Pharmacy
|
$200
|
$500
|
$800
|
All other services
|
N/A
|
$750
|
$1,500
|