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Copayments, Groups and Plans

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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