Page 12 - QCS.19 Employee Benefits

What You Will Pay Limitations, Exceptions, &
Other Important Information
vider Out-of-Network Provider
not covered.
e least) (You will pay the most)

ctible, and

scription, or Not covered
ay/

y/visit 50% coinsurance Prior Authorization is required. If
apply you don't get Prior Authorization,
surance Physician: 50%coinsurance benefits could be reduced by
rance Surgeon: 50% coinsurance 50% of the total cost of the
visit and service.
Physician: 0% coinsurance*
ay/visit Facility: $300 copay/visit and Out-of-network emergency
apply 0% coinsurance* services are covered at the
visit 0% coinsurance* Network benefit level.
apply
Physician: 50% coinsurance One copay is applied per network
y/visit Facility: 50% coinsurance urgent care visit.
apply
urance 50% coinsurance Prior Authorization is required. If
you don't get Prior Authorization,
y/visit Physician: 50% coinsurance benefits could be reduced by
apply Surgeon: 50% coinsurance 50% of the total cost of the
rance for service.
ces
y/visit Physician:50% coinsurance Prior Authorization is required for
apply Facility: 50% coinsurance inpatient services. If you don't get
rance Prior Authorization, benefits
Physician: 50% coinsurance could be reduced by 50% of the
apply Facility: 50% coinsurance total cost of the service.

50% coinsurance Cost sharing does not apply to
certain preventive services.
Depending on the type of
services, coinsurance mayapply.

ument at www.myallsavers.com. 3 of 6