Page 97 - QCS.19 SPD - HSA

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies

What You Will Pay
Common Limitations, Exceptions, & Other
Services You May Need Network Provider Out-of-Network Provider
Medical Event Important Information
(You will pay the least) (You will pay the most)

Primary care visit to treat an $30 copay/0% coinsurance 50% coinsurance
injury or illness None

If you visit a health Specialist visit $60 copay/0% coinsurance 50% coinsurance

care provider's office Preventive care/screening/ No Charge 50% coinsurance You may have to pay for services that
or clinic immunization aren't preventive. Ask your provider if the

services you need are preventive. Then

check what your plan will pay for.

Diagnostic test (x-ray, blood Physician: 0% coinsurance Physician: 50% Sleep studies require a Prior Authorization
If you have a test
work) coinsurance or benefits could be reduced by 50% of the

Facility: 0% coinsurance Facility: 50% coinsurance total cost of the service.

Imaging (CT/PET scans, MRIs) Physician: 0% coinsurance Physician: 50% coinsurance Prior Authorization is required. If you don't

get Prior Authorization, benefits could be

Facility: 0% coinsurance Facility: 50% coinsurance reduced by 50% of the total cost of the
service.

Covers up to a 30-day supply (retail
$10 retail copay or $25 mail- Out-of-Network pharmacies
Tier 1 drugs subscription);
order copay per prescription are not covered.
If you need drugs to 31-90 day supply (mail prescription)
treat your illness or If a dispensed drug has a chemically
$35 retail copay or $88 mail- Out-of-Network pharmacies
condition Tier 2 drugs equivalent drug at a lower tier, the cost
order copay per prescription are not covered.
difference between drugs in addition to any

More information about $60 retail copay or $150 Out-of-Network pharmacies applicable copay and/or coinsurance may

prescription drug Tier 3 drugs mail-order copay per are not covered. be applied.
coverage is available at prescription

www.myallsavers.com $100 retail copay or $250
Out-of-Network pharmacies Out-of-Network pharmacies are not
Tier 4 drugs mail-order copay per
are not covered. covered.
prescription

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