Page 11 - QCS.19 Employee Benefits

Common Services You May Need Network Prov
Medical Event (You will pay the

Tier 4 drugs $0 pharmacydeduc
$250 retail copay/pres
$625 mail-order copa

prescription

If you have outpatient Facility fee (e.g., ambulatory 0% coinsurance
surgery surgery center)
Physician/surgeon fees Physician: $60 copay
If you need immediate Deductible does not a
medical attention Emergency room care Surgeon: 0% coins
Emergency medical Physician: 0% coinsu
transportation Facility: $300 copay/v
0% coinsuran$c3e0
Urgent care 0% coinsurance

Facility fee (e.g., hospital room) Physician: $100 copa
Deductible does not a
Facility: $100 copay/v
Deductible does not a
0% coinsurance

If you have a hospital Physician: $60 copay
stay Physician/surgeon fees Deductible does not a

Surgeon: 0% coinsu

If you need mental Outpatient services Physician:$60 copay
health, behavioral Inpatient services
health, or substance Deductible does not a
abuse services Facility: 0% coinsur
other outpatient servic

Physician: $60 copay
Deductible does not a

Facility: 0% coinsur

If you are pregnant Office visits $30 copay/visit
Deductible does not a

* For more information about limitations and exceptions, see the plan or policydocu