Page 22 - QCS.19 Employee Benefits

see a specialist?

All copayment and coinsurance costs shown in this chart are after your ded

Common Services You May Need Network Provi
Medical Event (You will pay the
Primary care visit to treat an
If you visit a health injury or illness $30 copay/ 0% coi
care provider’s office Specialist visit $60 copay/ 0% coi
or clinic
Preventive care/screening/ No charge
immunization

Diagnostic test (x-ray, blood Physician: 0% coins
work) Facility: 0% coinsur

If you have a test

Imaging (CT/PET scans, MRIs) Physician: 0% coins
Facility: 0% coinsur

Tier 1 drugs $10 retail copay/pres

If you need drugs to Tier 2 drugs or
treat your illness or Tier 3 drugs $25 mail-order copa
condition prescription

More information about $35 retail copay/pres
prescription drug or
coverage is available at $88 mail-order copa
www.myallsavers.com prescription
$60 retail copay/pres
Tier 4 drugs or
$150 mail-order copa

prescription

$100 retail copay/pres
or

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