healthgram

Summary of Benefits

Services:	Benefit:**
Primary care physician services Office visits	100% after $15 copay
Preventive care/wellness Routine well-child exams Well-adult care, PCP or GYN Well-adult care, specialist Gynecological exam Mammogram Prostate screening & rectal exam Limit: one per calendar year	100%, no copay
Specialist physician services Office visits	100% after $25 copay
Urgent care	100% after $25 copay
Emergency room care	100% after $100 copay
Ambulatory surgery centers*	100% after $50 copay
Hospital services* Outpatient Inpatient	100% after $150 copay 100% after $250 copay
Prescription drug benefits*** Retail: 34-day supply Generic Preferred brand name Non-preferred brand name	$10 copay $25 copay $40 copay
Lifetime maximum	$2,000,000
Deductible and coinsurance limit	Do not apply
We encourage you to contact our Healthgram patient advocacy team at 1-877-371-3720 prior to receiving services to obtain a pretreatment estimate and assistance with scheduling. You can reach our Hispanic voicemail line by dialing extension 3122. For additional information about covered and excluded benefits, please visit www.healthgram.com. * Requires precertification. Visit www.healthgram.com to view the plan document. Benefit payment is based on Healthgram's fee schedule, which can be found at www.healthgram.com. * This is an example of a prescription drug benefit. This may vary by employer.