Page 37 - University of the South-2022-Benefit Guide REVISED 3.30.22 FSA WAIT PERIOD

What You Will Pay
Common Out-of-Network Limitations, Exceptions, & Other Important
Medical Event Services You May Need In-Network Provider Provider Information
(You will pay the least)
(You will pay the most)
$25 copay/visit
Primary care visit to treat PhysicianNow - Powered by MDLIVE: $15
an injury or illness deductible does not 40% coinsurance copay

apply.
$45 copay/visit
Specialist visit deductible does not 40% coinsurance Office surgery subject to office copay.
If you visit a health
care provider’s apply.
office or clinic A1c testing will be covered at 100%. You may
have to pay for services that aren’t
Preventive
care/screening/ No Charge 40% coinsurance preventive. Ask your provider if the services
immunization needed are preventive. Then check what your
plan will pay for. Travel immunization not
covered in office or clinic setting.
Diagnostic test (x-ray, No Charge 40% coinsurance Diagnostic testing benefits are determined by
blood work) place of service, such as office or ER.
If you have a test
Imaging (CT/PET scans, 20% coinsurance 40% coinsurance None
MRIs)
30 day supply for Retail Network; up to 90
$15 copay/prescription
Generic drugs deductible does not 40% coinsurance day supply for Home Delivery or Plus90
Network. 2 times Retail Copayment up to 90
apply.
day supply.
If you need drugs $40 copay/prescription 30 day supply for Retail Network; up to 90
to treat your Preferred brand drugs deductible does not 40% coinsurance day supply for Home Delivery or Plus90
illness or condition apply. Network. 2 times Retail Copayment up to 90
More information day supply. When a brand drug is chosen and
about prescription a generic drug equivalent is available, you will
drug coverage is Non-preferred brand $65 copay/prescription pay a penalty for the difference between the
available at drugs deductible does not 40% coinsurance cost of the brand drug and the generic drug,
www.bcbst.com/rxp apply. plus the generic drug copayment or
coinsurance.
$130 copay/prescription
Specialty drugs deductible does not Not Covered Up to a 30 day supply. Must use a pharmacy
in the Preferred Specialty Pharmacy Network.
apply.
Facility fee (e.g., Prior Authorization required for certain
ambulatory surgery 20% coinsurance 40% coinsurance outpatient procedures. Your cost share may
If you have center) increase to 50% if not obtained.
outpatient surgery Prior Authorization required for certain
Physician/surgeon fees 20% coinsurance 40% coinsurance outpatient procedures. Your cost share may
increase to 50% if not obtained.
$150 copay/visit $150 copay/visit
Emergency room care deductible does not deductible does not None
If you need apply. apply.
immediate medical Emergency medical 20% coinsurance 20% coinsurance None
attention transportation
$45 copay deductible
Urgent care 40% coinsurance Office surgery subject to office copay.
does not apply.

37