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.
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.