Benefit Explanation: First 3 visits subject to copay. Visits 4+ subject to deductible and coinsurance. You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our Sydney application.
Specialist
CoPay: No Charge after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: You may also be able to access care with lower cost shares using our online virtual doctor visits and medical chat with a doctor. These can be accessed via our Sydney application.
Prescription Drug Information
Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Cost share shown is for a 30 day supply.
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Cost share shown is for a 30 day supply.
Generic Drugs
CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Cost share shown is for a 30 day supply.
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Cost share shown is for a 30 day supply.
Inpatient Coverage
Hospital Services
CoPay: No Charge after deductible
CoInsurance: Not Applicable
Covered: Covered
Inpatient Services
CoPay: No Charge after deductible
CoInsurance: Not Applicable
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: No Charge after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Emergency Room copay is waived if directly admitted to the hospital.