Benefit Explanation: Copay applies for the first 3 visits for Primary care, Retail Health Clinic and Chiropractic office visits combined. Additional office visits are subject to the deductible. 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: $60.00 Copay 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: $45.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Cost share is for a 30 day supply. 90 day supply is available with additional cost shares.
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Cost share is for a 30 day supply. 90 day supply is available with additional cost shares.
Generic Drugs
CoPay: $20.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Cost share is for a 30 day supply. 90 day supply is available with additional cost shares.
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Cost share is for a 30 day supply.
Inpatient Coverage
Hospital Services
CoPay: $500.00 Copay per Stay 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: $500.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: If applicable, copay waived if admitted.
Urgent Care Facility
CoPay: $50.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Maternity
Labor and Delivery Hospital Stay
CoPay: $500.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Pre and Postnatal Office Visit
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Vision
Routine Eye Exams For Children
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Year
Benefit Explanation: This Plan covers a complete eye exam and if needed, dilation.