Page 14 - PWH.19 Employee Benefits

to see a specialist?

All copayment and coinsurance costs shown in this chart are after you

Common Services You May Need W
Medical Event In-Network Prov
Primary care visit to treat an (You will pay the
If you visit a injury or illness
health care Specialist visit 0% coinsuranc
provider’s office 0% coinsuranc
or clinic Preventive care/screening/
immunization No charge

If you have a test Diagnostic test (x-ray, blood 0% coinsuranc
work) 0% coinsuranc
Imaging (CT/PET scans, MRIs)

If you need drugs Tier 1 - Typically Generic $10/prescription (
to treat your and home delive
illness or Tier 2 - Typically Preferred /
condition Brand $35/prescription
More information $88/prescription (r
about prescription Tier 3 - Typically Non-Preferred
drug coverage is / Specialty Drugs $70/prescription (r
available at and $175/prescrip
http://www.anthe Tier 4 - Typically Specialty
m.com/pharmacyin (brand and generic) (home delivery
formation/ 25% coinsurance u
Facility fee (e.g., ambulatory $200/prescription (
If you have surgery center) and 25% coinsuranc
outpatient surgery Physician/surgeon fees $200/prescription (
Emergency room care
If you need Emergency medical delivery)
immediate transportation
medical attention Urgent care 0% coinsuranc

If you have a Facility fee (e.g., hospital room) 0% coinsuranc
hospital stay 0% coinsuranc

0% coinsuranc

0% coinsuranc

0% coinsuranc

* For more information about limitations and exceptions, see plan or policy d