Page 23 - QCS.19 Employee Benefits
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ductible has been met, if a deductible applies.
What You Will Pay Limitations, Exceptions, &
Other Important Information
ider Out-of-Network Provider
least) (You will pay the most)
insurance 50% coinsurance None
insurance 50% coinsurance
You may have to pay for services
50% coinsurance that aren’t preventive. Ask your
provider if the services you need
surance Physician: 50% coinsurance are preventive. Then check what
rance 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.
scription, Prior Authorization is required. If
ay/ 50% coinsurance you don't get Prior Authorization,
scription, benefits could be reduced by
ay/ 50% coinsurance 50% of the total cost of the
scription, service.
ay/ 50% coinsurance
scription, 50% coinsurance Covers up to a 30-day supply
(retail subscription); 31-90 day
supply (mail prescription).
If a dispensed drug has a
chemicallyequivalent drug at a
lower tier, the cost difference
between drugs in addition to any
applicable copayand/or
coinsurance maybe applied.
ument at www.myallsavers.com. 2 of 6
