Benefit Explanation: Copay applies to PCP office visit charge only, all other services subject to deductible & 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: $75.00
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: $40.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Cost share shown is for a 30 day supply.
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Cost share shown is for a 30 day supply.
Generic Drugs
CoPay: $15.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Cost share shown is for a 30 day supply.
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Cost share shown is for a 30 day supply.
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Maximum 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis).
Inpatient Services
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: $500.00 Copay after deductible
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Urgent Care Facility
CoPay: $75.00
CoInsurance: Not Applicable
Covered: Covered
Maternity
Labor and Delivery Hospital Stay
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Pre and Postnatal Office Visit
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Vision
Routine Eye Exams For Children
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Benefit Period
Benefit Explanation: Eye exams are covered once per benefit period for In Network Services.
1-817-813-4562, TTY 711
