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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 |