Page 9 - 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 Prov
Medical Event (You will pay the
$30 copay/visit.
Primary care visit to treat an Deductible does not a
injury or illness $60 copay/visit.
Deductible does not a
If you visit a health Specialist visit
care provider’s office No charge
Preventive care/screening/
or clinic immunization

Diagnostic test (x-ray, blood Physician: No charge
work) Facility: No charge

If you have a test

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

Tier 1 drugs $0 pharmacydeduc
$15 retail copay/pres
If you need drugs to Tier 2 drugs $38 mail-order copa
Tier 3 drugs prescription
treat your illness or
condition $0 pharmacydeduc
More information about
prescription drug $35 retail copay/pres
$88 mail-order copa
coverage is available at prescription
www.myallsavers.com
$0 pharmacydeduc
$75 retail copay/pres
$188 mail-order copa
prescription

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