Plan Details
Costs and Other Important Information
Benefits
$10 per visit
Specialist:
$30 per visit
$80 per visit (always covered)
Urgent care:
$50 per visit (always covered)
$0-10
Lab services:
$0-10
Diagnostic radiology services (e.g., MRI):
$100
Outpatient x-rays:
$25
Outpatient group therapy visit with a psychiatrist:
$30
Outpatient individual therapy visit with a psychiatrist:
$30
Outpatient group therapy visit:
$30
Outpatient individual therapy visit:
$30
$167.50 for days 21 through 100
$30
Physical therapy and speech and language therapy visit:
$30
$30
Routine foot care:
$30
20% per item
Prosthetics (e.g., braces, artificial limbs):
20% per item
Diabetes supplies:
0-20% per item
20%
Other Part B drugs:
20%
Coverage Area for Security Blue HMO Standard (HMO)
State | Pennsylvania |
---|---|
County | Philadelphia |
Cost Sharing Information
All cost-sharing assumes in-network healthcare providers.
Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit
30 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
---|---|---|---|
Tier 1: Preferred Generic | Not offereds | $0 copay | Not offered |
Tier 2: Non-Preferred Generic | Not offered | $13 copay | Not offered |
Tier 3: Preferred Brand Name | Not offered | $44 copay | Not offered |
Tier 4: Non-Preferred Brand Name | Not offered | $100 copay | Not offered |
Tier 5: Specialty Tier | Not offered | 33% coinsurance | Not offered |
90 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
---|---|---|---|
Tier 1: Preferred Generic | Not offered | $0 copay | Not offered |
Tier 2: Non-Preferred Generic | Not offered | $39 copay | Not offered |
Tier 3: Preferred Brand Name | Not offered | $132 copay | Not offered |
Tier 4: Non-Preferred Brand Name | Not offered | $300 copay | Not offered |
Tier 5: Specialty Tier |
CMS Ratings
Staying healthy - screenings, tests and vaccines
Managing Chronic Conditions
Member Experience with Health Plan
Member Complaints, and Changes in Health Plan's Performance
Health Plan Customer Service
Drug Plan Customer Service
Member Complaints, and Changes in Drug Plan's Performance
Member Experience with Drug Plan
Drug Pricing and Patient Safety
Physician Finder
Physicians that accept Security Blue HMO Standard (HMO) for Pennsylvania