Know Your Medical Service Co-Pays

(These co-pays were effective as of July 2015 and are for members not covered by SWSCHP/Aetna Medicare Advantage.)

Medical:                                                        $30      Co-Pay for Participating Provider Services

Hospital Emergency Room Visits:                $75     Co-Pay

Hospital, In-Patient:                                      $200    Co-Pay Per In-Patient Admission

Hospital, Out-Patient Lab/X-ray                     $50      Co-Pay for Lab and X-Ray

Lab Services by Quest Diagnostics $0 Co-Pay for Lab Services

Hospital, Out-Patient Surgery                        $75 Co-Pay

Hospital, Out-Patient High-Tech Radiology              $75 Co-Pay (MRI, MRA, CT, CTA, and Pet Scans (with or without contrast))

Hospital, Out-Patient High-Tech Radiology              $0 Co-Pay (No co-pay for using US Imaging for high tech diagnostic radiology)

Prescription Drug Co-Pays

Retail Pharmacy
30 Day Supply

Generic               $7.50                          After 1st Refill– $15.00

Brand                  $30.00                       After 1st Refill– $60.00

Non-Preferred     $50.00                      After 1st Refill – $100.00

Accredo Specialty Pharmacy (1-800-501-7260) is not available at retail pharmacies. Mail order pharmacy Co-Pays are as follows

30-day supply $16.67
60-day supply $33.33
90-day supply $50.00

Note: If you purchase a brand name medication when a generic medication is available, you will pay the appropriate co-payment, plus the difference in cost between the brand name medication and the generic medication.