Effective
January 1, 2014 |
|
Charge |
Enrollment Fees (for 12-month enrollment period): |
|
At or below 151% of FPL* |
$0 |
Above 151% up to and including 186% of FPL |
$35 |
Above 186% up to and including 201% of FPL |
$50 |
|
|
Co-Pays (per visit): |
|
At or below 151% FPL |
|
Office Visit (non-preventative) |
$5 |
Non-Emergency ER |
$5 |
Generic Drug |
$0 |
Brand Drug |
$5 |
Facility Co-pay, Inpatient (per admission) |
$35 |
Cost-sharing Cap |
5% (of family's income)** |
Above 151% up to and including 186% FPL |
|
Office Visit (non-preventative) |
$20 |
Non-Emergency ER |
$75 |
Generic Drug |
$10 |
Brand Drug |
$35 |
Facility Co-pay, Inpatient (per admission) |
$75 |
Cost-sharing Cap |
5% (of family's income)** |
Above 186% up to and including 201% FPL |
|
Office Visit (non-preventative) |
$25 |
Non-Emergency ER |
$75 |
Generic Drug |
$10 |
Brand Drug |
$35 |
Facility Co-pay, Inpatient (per admission) |
$125 |
Cost-sharing Cap |
5% (of family's income)** |
|
|
*The federal poverty level (FPL) refers to income guidelines established annually by the federal government.
**Per 12-month term of coverage.
Contact the DentaQuest Member Call Center for information about benefit limits and frequency toll-free at 1-800-508-6775. |