Benefit and co-payment summary by plan type

• Plan Type I 
• Plan Type II
• Plan Type III

What is a medical co-payment?

• A medical co-payment is a fixed amount you may have to pay for a covered service other than pharmacy.
• Some examples of covered services that require you to pay a co-payment are doctors’ visits and nonemergency hospital care.
• Please see the benefit and co-payment summary for your plan type to find your co-payment amounts and cap.

How does the medical co-payment cap work?

• Services that require co-payments count toward your yearly medical co-payment cap.
• Once you have been charged the maximum in medical co-payments in a benefit year (January 1 to December 31), you no longer have to pay medical co-payments until the next benefit year.
• We’ll send you a letter telling you that you have reached your medical co-payment cap.

 What is a pharmacy co-payment?

• A pharmacy co-payment is a fixed amount you may pay for a covered medication.
• There is a yearly pharmacy co-payment cap (or limit on what you will be charged) for medications.

How much is a pharmacy co-payment?

• Please see the benefit and co-payment summary for your plan type to find your co-payment amounts and cap.
• To determine a specific medication’s co-payment, please use our Drug Lookup.
• Pregnant women are exempt from pharmacy co-payments. 

How does the co-payment cap work?

• Once you have been charged the maximum amount in pharmacy co-payments in a benefit year (January 1 to December 31), you no longer have to pay pharmacy co-payments until the next benefit year. This is called a pharmacy co-payment cap.
• We’ll send you a letter telling you that you have reached your pharmacy co-payment cap.