Benefits + Costs by Plan Level

When you get services, you may have to pay out-of-pocket costs.

View the Schedule of Benefits for your plan level. These summaries give you information about the costs you have to pay for covered services.

Please note: For certain services, your provider needs to ask us for a prior authorization before sending you to get those services. Your provider knows when and how to ask us for prior authorization if it is required.

2024 Schedule of Benefits: