Page 25 - QCS.19 Employee Benefits

What You Will Pay Limitations, Exceptions, &
Other Important Information
ider Out-of-Network Provider
Prior Authorization is required. If
least) (You will pay the most) you don't get Prior Authorization,
benefits could be reduced by
ay/ 50% of the total cost of the
service.
50% coinsurance
*Out-of-network emergency
y/visit Physician: 50% coinsurance services are covered at the
urance Surgeon: 50% coinsurance network benefit level.

surance Physician: 0% coinsurance*
y/visit and Facility: $300 copay/visit and

0% coinsurance*

0% coinsurance*

ay/visit and One copay is applied per network
urgent care visit.
Physician: 50% coinsurance
y/visit and Facility: 50% coinsurance Prior Authorization is required. If
you don't get Prior Authorization,
50% coinsurance benefits could be reduced by
50% of the total cost of the
pay/visit Physician: 50% coinsurance service.
Surgeon: 50% coinsurance
e Prior Authorization is required for
urance inpatient services. If you don't get
Prior Authorization, benefits
ay/visit and Physician: 50% coinsurance could be reduced by 50% of the
Facility: 50% coinsurance total cost of the service.
rance/
ces Physician: 50% coinsurance Cost sharing does not apply to
ay/visit and Facility: 50% coinsurance certain preventive services.
Depending on the type of
rance services, coinsurance mayapply.
Maternity care may include tests
50% c oinsuranc e

50% c oinsuranc e
50% coinsurance

ument at www.myallsavers.com. 3 of 6