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2017 Benefits Enrollment 3 of 8
Limitations & Exceptions Coverage is limited to up to a 30-day supply retail and up to a 90-day supply home delivery. Coverage is limited to up to a 30-day supply retail and up to a 90-day supply home delivery. Coverage is limited to up to a 30-day supply retail and up to a 90-day supply home delivery. $750 penalty for no precertification. $750 penalty for no precertification. -----------none----------- -----------none----------- -----------none--
Out-of-Network Provider 40% co-insurance (retail) Not Covered (home delivery) 40% co-insurance (retail) Not Covered (home delivery) 40% co-insurance (retail) Not Covered (home delivery) 40% co-insurance 40% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance 40% co-insurance 40% co-insurance 40% co-insurance 40% co-insurance 40% co-insurance 40% co-insurance
Your Cost if you use an
In-Network Provider 20% co-insurance (retail) 20% co-insurance (home delivery) 20% co-insurance (retail) 20% co-insurance (home delivery) 20% co-insurance (retail) 20% co-insurance (home delivery) 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance
Services You May Need Generic drugs Preferred brand drugs Non-preferred brand drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room services Emergency medical transportation Urgent care Facility fee (e.g., hospital room) Physician/surgeon fees Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpati
Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.express-scripts.com If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs
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Limitations & Exceptions Coverage is limited to up to a 30-day supply retail and up to a 90-day supply home delivery. Coverage is limited to up to a 30-day supply retail and up to a 90-day supply home delivery. Coverage is limited to up to a 30-day supply retail and up to a 90-day supply home delivery. $750 penalty for no precertification. $750 penalty for no precertification. -----------none----------- -----------none----------- -----------none--
Out-of-Network Provider 40% co-insurance (retail) Not Covered (home delivery) 40% co-insurance (retail) Not Covered (home delivery) 40% co-insurance (retail) Not Covered (home delivery) 40% co-insurance 40% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance 40% co-insurance 40% co-insurance 40% co-insurance 40% co-insurance 40% co-insurance 40% co-insurance
Your Cost if you use an
In-Network Provider 20% co-insurance (retail) 20% co-insurance (home delivery) 20% co-insurance (retail) 20% co-insurance (home delivery) 20% co-insurance (retail) 20% co-insurance (home delivery) 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance 20% co-insurance
Services You May Need Generic drugs Preferred brand drugs Non-preferred brand drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees Emergency room services Emergency medical transportation Urgent care Facility fee (e.g., hospital room) Physician/surgeon fees Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services Substance use disorder inpati
Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.express-scripts.com If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs
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