Service Copayment definition

Service Copayment means the Copayment the Enrollee must pay for each dental service. Service Copayments are in addition to the General Office Visit Copayment or the Specialist Office Visit Copayment.
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Examples of Service Copayment in a sentence

  • The Member should submit the applicable Mail Service Copayment, an order form and his Blue Shield Member number to the address indicated on the mail order envelope.

  • Click “Forms” on the main Service Copayment per 30 day supply Mail order 90-day supply Tier 1 ● Low cost generics $7 $7 (maintenance) $21 (non-maintenance) Tier 2 ● Higher cost generics ● Preferred brand name drugs $25 $25 (maintenance) $75 (non-maintenance) bar at the top of the Screen.

  • Further, Contracted Provider agrees not to implement any policy that would circumvent the obligation of the Member to pay any Non-Covered Service, Copayment, Deductible, and/or Coinsurance amounts as provided in the applicable Benefit Contract.

  • Ambulance Service Co-payment $60 Rx – Co-Pays Generic – 2009 -$10.00 ** 2010 - $11.00 ** Formulary Brand - $22.00 ** Non-formulary Brand - $44.00 ** ** two co-pays for 90 day supply DENTAL • Annual cap = $2,500 • No deductible • Co-pay = $20/visit • Orthodontia coverage = 50% split • Routine cleaning & x-rays = free twice a year A.

  • Ambulance Service Co-payment $ 60 (2009-2011) Rx – Co-Pays Generic – 2011 - $12.00 ** 2012 - $12.00 ** 2013 - $12.00 ** Formulary Brand - $22.00 ** Non-formulary Brand - $44.00 ** Effective 2012 Formulary Brand - $24.00 ** 2012 Non-formulary Brand - $48.00 ** ** two co-pays for 90 day supply DENTAL • Annual cap = $2,500 • No deductible • Co-pay = $20/visit • Orthodontia coverage = 50% split • Routine cleaning & x-rays = free twice a year A.

  • Ambulance Service Co-payment $ 60 (2009-2011) Rx – Co-Pays Generic – 2009 - $10.00 ** 2010 - $11.00 ** 2011 - $12.00 ** Formulary Brand - $22.00 ** Non-formulary Brand - $44.00 ** ** two co-pays for 90 day supply DENTAL • Annual cap = $2,500 • No deductible • Co-pay = $20/visit • Orthodontia coverage = 50% split • Routine cleaning & x-rays = free twice a year A.

  • To obtain prescription Drugs through the Mail Service Pro- gram, the Member should submit the applicable Mail Service Copayment*, order form, and his Blue Shield Member num- ber to the address indicated on the mail service envelope.

  • Ambulance Service Co-payment $ 60 (2010-2012) Rx – Co-Pays Generic – 2010 - $11.00 ** 2011 - $12.00 ** 2012 - $12.00 ** Formulary Brand - $22.00 ** Non-formulary Brand - $44.00 ** Effective 2012 Formulary Brand - $24.00 ** 2012 Non-formulary Brand - $48.00 ** ** two co-pays for 90 day supply DENTAL • Annual cap = $2,500 • No deductible • Co-pay = $20/visit • Orthodontia coverage = 50% split • Routine cleaning & x-rays = free twice a year A.

  • Back to Table of Contents APPENDIX B DENTAL PLAN PROVISIONS Service Co-payment: Plan/Member> Diagnostic and Preventive Services: 100% / 0% Routine and Restorative Services: 80% / 20% after $25 deductible per year for single, $75 for family Major Restorative Care: 50% / 50% after $25 deductible per year for single, $75 for family Orthodontics: No coverage Maximum annual benefit of $1,000 per person, exclusive of accident care covered under Medicaid.

  • The Orthodontic Service Copayment must be paid in full prior to commencement of orthodontic treatment.