Page 8 - RTF.20 Employee Benefits

Network Provider What You Will Pay Exceptions, & Limitations, Out-of-Network Provider Other Important Information (You will pay the most) (You will pay the least) pharmacy), you may be retail copay/prescription, or $250 retail copay/prescription, or $250 responsible for any amount over Deductible does not apply. Deductible does not apply. the allowed amount. mail-order copay/ prescription $625 mail-order copay/ pres

Services You May Need Tier 4 drugs Facility fee (e.g., 0% ambulatory surgery center) Physician/surgeon fees Emergency room services Emergency medical 0% transportation Urgent care Facility fee (e.g., 0% hospital room) Physician/surgeon fees Outpatient services Inpatient services Office visits

Common Medical Event If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you need mental health, behavioral health, or substance abuse services If you are pregnant