Page 10 - QCS.19 Employee Benefits

ductible has been met, if a deductible applies.

What You Will Pay Limitations, Exceptions, &
Other Important Information
vider Out-of-Network Provider

e least) (You will pay the most)

apply 50% coinsurance None
apply 50% coinsurance
You may have to pay for services
50% coinsurance that aren’t preventive. Ask your
provider if the services you need
e Physician: 50% coinsurance are preventive. Then check what
Facility: 50% coinsurance your plan will pay for.
Sleep studies require a Prior
surance Physician: 50% coinsurance Authorization or benefits could be
rance Facility: 50% coinsurance reduced by 50% of the total cost
of the service.
ctible, and Prior Authorization is required. If
you don't get Prior Authorization,
scription, or Not covered benefits could be reduced by
ay/ 50% of the total cost of the
service.

Covers up to a 30-day supply
(retail subscription); 31-90 day
supply (mail prescription).

ctible, and If a dispensed drug has a
chemicallyequivalent drug at a
scription, or Not covered lower tier, the cost difference
ay/ between drugs in addition to any
applicable copayand/or
ctible, and coinsurance maybe applied.

scription, or Not covered Out-of-network pharmacies are
ay/

ument at www.myallsavers.com. 2 of 6