v1.0 2 of 6 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network Provider (You pay the least) Out-of-Network Provider (You pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $25 copay/visit; deductible waived Not covered You may have to pay for services that aren’t preventive. Ask your provider if services are preventive. Then check what your plan will pay. Telemedicine visit – Doctor On Demand $1 copay/visit; deductible waived Not covered Specialist visit $25 copay/visit; deductible waived Not covered Preventive care/screening/immunization No charge; deductible waived Not covered If you have a test Diagnostic test (x-ray, blood work) No charge; deductible waived Not covered None Imaging (CT/PET scans, MRIs) $150 copay/day; deductible waived Not covered If you need drugs to treat your illness or condition. More information about prescription drug coverage is available at hpiTPA.com Generic drugs— Retail (30 days) Retail (90 days)/Mail Order (90 days) $5 copay/prescription $10 copay/prescription Not covered Deductible waived Preferred drugs— Retail (30 days) Retail (90 days)/Mail Order (90 days) $35 copay/prescription $70 copay/prescription Not covered Non-preferred drugs— Retail (30 days) Retail (90 days)/Mail Order (90 days) $50 copay/prescription $100 copay/prescription Not covered Specialty drugs---Retail/Mail Order (30 days) $50 copay/prescription Not covered If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) deductible only Not covered Preauthorization required for total joint replacement & non-emergent spine surgeries Physician/surgeon fees deductible only Not covered If you need immediate medical attention Emergency room care $150 copay/visit; deductible waived Copay waived if admitted Emergency medical transportation In-network deductible only None Urgent care $25 copay/visit; deductible waived None If you have a hospital stay Facility fee (e.g., hospital room) deductible only Not covered Preauthorization required Physician/surgeon fees deductible only Not covered