Page 44 - 2023 Hickory Crawdads - Benefits Guide_Neat

What You Will Pay
Common Medical Services You May Need Limitations, Exceptions, & Other
Event Network Provider (You Out-of-Network Provider Important Information
will pay the least) (You will pay the most)
If you need drugs Generic drugs $20 copay/prescription Not covered Up to 31-day supply retail pharmacy.
to treat your (retail) Up to 90-day supply mail order.
illness or $40 copay/prescription
condition (mail order)
Formulary Brand drugs $30 copay/prescription Not covered
More information (retail)
about prescription $60 copay/prescription
drug coverage is (mail order)
available at Non-Formulary Brand drugs $60 copay/prescription Not covered
www.highmarkbcbs. (retail)
com/find-a- $120 copay/prescription
doctor/#/drug. (mail order)

If you have Facility fee (e.g., ambulatory surgery 20% coinsurance 40% coinsurance Precertification may be required.
outpatient surgery center)
Physician/surgeon fees 20% coinsurance 40% coinsurance No charge for second surgical opinion.
Precertification may be required.
If you need Emergency room care 20% coinsurance after $50 20% coinsurance after $50 Copay waived if admitted as an
immediate medical copay/visit copay/visit inpatient.
attention Deductible does not apply. Deductible does not apply.
Emergency medical transportation 20% coinsurance 20% coinsurance −−−−−−−−−−−none−−−−−−−−−−−
Deductible does not apply. Deductible does not apply.
Urgent care $20 copay/visit 40% coinsurance −−−−−−−−−−−none−−−−−−−−−−−
Deductible does not apply.
If you have a Facility fees (e.g., hospital room) 20% coinsurance 40% coinsurance Precertification may be required.
hospital stay Failure to precertify will result in
benefits payable being reduced by
$250.
Physician/surgeon fees 20% coinsurance 40% coinsurance No charge for second surgical opinion.
Precertification may be required.

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