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 20% coinsurance 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 – Doctor On Demand $1 copay/visit; deductible waived 20% coinsurance Specialist visit $25 copay/visit; deductible waived 20% coinsurance Preventive care/screening/immunization No charge; deductible waived 20% coinsurance If you have a test Diagnostic test (x-ray, blood work) No charge; deductible waived 20% coinsurance None Imaging (CT/PET scans, MRIs) $150 copay/day; deductible waived 20% coinsurance 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 20% coinsurance Deductible waived Preferred drugs— Retail (30 days) Retail (90 days)/Mail Order (90 days) $35 copay/prescription $70 copay/prescription 20% coinsurance Non-preferred drugs— Retail (30 days) Retail (90 days)/Mail Order (90 days) $50 copay/prescription $100 copay/prescription 20% coinsurance Specialty drugs---Retail/Mail Order (30 days) $50 copay/prescription 20% coinsurance If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) deductible only 20% coinsurance Preauthorization required for total joint replacement & non-emergent spine surgeries Physician/surgeon fees deductible only 20% coinsurance 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 20% coinsurance None If you have a hospital stay Facility fee (e.g., hospital room) deductible only 20% coinsurance Preauthorization required Physician/surgeon fees deductible only 20% coinsurance