Know Your Co-Pays

Co-pays Effective July 1, 2015

(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:                                   $50      Co-Pay for the Following Out-Patient Procedures:

• Hospital-based outpatient Lab and X-Ray

Eliminating co-pays for lab services provided by Quest.

Hospital, Out-Patient:                                   $75 Co-Pay for the Following Out-Patient Procedures:

     • Surgery

     • High Tech Diagnostic Radiology – MRI, MRA, CT, CTA, and Pet Scans (with or without contrast)

     • There is 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.