Page 54 - Avatar 2022 Flipbook

What You Will Pay

Common Medical Services You May Need Network Provider Out-of-Network Limitations, Exceptions, & Other
Event (You will pay the Provider (You will Important Information
least) pay the most)
If you need drugs Generic drugs 30% coinsurance Not covered Up to 31-day supply retail pharmacy.
to treat your illness (retail) Up to 90-day supply maintenance
or condition 30% coinsurance prescription drugs through mail order.
(mail order)
More information Brand drugs 30% coinsurance Not covered
about prescription (retail)
drug coverage is 30% coinsurance
available at (mail order)
www.highmarkbcbs.
com/find-a-
doctor/#/drug.
If you have Facility fee (e.g., ambulatory surgery center) 30% coinsurance 50% coinsurance Precertification may be required.
outpatient surgery Physician/surgeon fees 30% coinsurance 50% coinsurance Precertification may be required.
If you need Emergency room care 30% coinsurance 30% coinsurance Out-of-network: Subject to network
immediate medical deductible.
attention Emergency medical transportation 30% coinsurance 30% coinsurance Out-of-network: Subject to network
deductible.
Urgent care 30% coinsurance 50% coinsurance The Copayment, if any, does not apply
to Urgent Care Services prescribed for
the treatment of Mental Health or
Substance Abuse.
If you have a Facility fees (e.g., hospital room) 30% coinsurance 50% coinsurance Precertification may be required.
hospital stay Out-of-network: Failure to precertify will
result in benefits payable being reduced
by $250.
Physician/surgeon fees 30% coinsurance 50% coinsurance Precertification may be required.

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