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Copayments, Groups and Plans
MAP Group ID: 53210000 |
MAP Basic Group ID: 53230000 |
MAP Basic Dental Only Group ID: 53220000 |
|
Primary Care Office Visit (including walk-in clinics) |
MAP 000: $0 MAP 100: $10 |
Basic 000: $0 Basic 100: $10 Basic 150: $15 Basic 175: $25 Basic 200: $30 |
Not a benefit. |
Specialty Care Office Visit | MAP 000: $0 MAP 100: $10Note: Copays may not be collected by the Physician for Professional Services conducted in the Ambulatory Surgery Center or Hospital facility settings. |
Basic 000: $0 Basic 100: $15 Basic 150: $25 Basic 175: $45 Basic 200: $55**Copays only apply to CommUnityCare Specialty Care clinics Services with Ascension Seton or other non-eligible MAP Basic providers subject to healthcare provider sliding fee scale or charity copay scale.Note: Copays may not be collected by the Physician for Professional Services conducted in the Ambulatory Surgery Center or Hospital facility settings. |
Not a Benefit. |
Ambulatory Surgery Centers | MAP 000: $0 MAP 100: $10Note: Copays are eligible for collection by the Ambulatory Surgery Center on the date of service. |
Basic 000: $0 Basic 100: $15 Basic 150: $25 Basic 175: $45 Basic 200: $55Note: Copays are eligible for collection by the Ambulatory Surgery Center on the date of service. |
Not a benefit. |
Primary Dental | MAP 000: $0 MAP 100: $10 |
Basic 000: $0 Basic 100: $10 Basic 150: $15 Basic 175: $25 Basic 200: $30 |
CUC 000: $0 CUC 100: $10 CUC 150: $15 CUC 175: $25 CUC 200: $30 |
Specialty Dental | MAP 000: $0 MAP 100: $10 |
Basic 000: $0 Basic 100: $15 Basic 150: $25 Basic 175: $45 Basic 200: $55 |
CUC 000: $0 CUC 100: $15 CUC 150: $25 CUC 175: $45 CUC 200: $55 |
Dentures | MAP 000: $0 MAP 100: $35 per arch |
Basic 000: $0 Basic 100: $35 per arch Basic 150: $35 per arch Basic 175: $35 per arch Basic 200: $35 per arch |
CUC 000: $0 CUC 100: $35 per arch CUC 150: $35 per arch CUC 175: $35 per arch CUC 200: $35 per arch |
Urgent Care | MAP 000: $0 MAP 100: $10 |
Not a MAP Basic benefit. Services subject to healthcare provider sliding fee scale or charity copay scale. | Not a benefit. |
Hospitalization / In-Patient | MAP 000: $0 MAP 100: $30 |
Not a MAP Basic benefit. Services subject to healthcare provider sliding fee scale or charity copay scale. | Not a benefit. |
Emergency Room | MAP 000: $0 MAP 100: $25 |
Not a MAP Basic benefit. Services subject to healthcare provider sliding fee scale or charity copay scale. | Not a benefit. |
Pharmacy Formulary (0-30 days supply) |
MAP 000: $0 MAP 100: $7 |
Basic 000: $0 Basic 100: $7 Basic 150: $8 Basic 175: $9 Basic 200: $10 |
CUC 000: $0 CUC 100: $7 CUC 150: $8 CUC 175: $9 CUC 200: $10 |
Pharmacy Formulary (31-90 days supply) |
MAP 000: $0 MAP 100: $14 |
Basic 000: $0 Basic 100: $14 Basic 150: $16 Basic 175: $18 Basic 200: $20 |
CUC 000: $0 CUC 100: $14 CUC 150: $16 CUC 175: $18 CUC 200: $20 |
Pharmacy Non-Formulary (0-30 days supply) |
MAP 000: $0 MAP 100: $10 |
Basic 000: $0 Basic 100: $10 Basic 150: $13 Basic 175: $14 Basic 200: $15 |
CUC 000: $0 CUC 100: $10 CUC 150: $13 CUC 175: $14 CUC 200: $15 |
Pharmacy Non-Formulary (31-90 day supply) |
MAP 000: $0 MAP 100: $20 |
Basic 000: $0 Basic 100: $20 Basic 150: $26 Basic 175: $28 Basic 200: $30 |
CUC 000: $0 CUC 100: $20 CUC 150: $26 CUC 175: $28 CUC 200: $30 |