Page 9 - RTF.21 Employee Benefits

Exceptions, & Other Important Information You may have to pay for services Ask your provider if the services you need Then check what Authorization or benefits could be is required. If pharmacy (including a mail order 2of 7

Limitations, None that aren’t preventive. are preventive. your plan will pay for. Sleep studies require a Prior reduced by 50% of the total cost of the service. Prior Authorization you don't get Prior Authorization, benefits could be reduced by 50% of the total cost of the service. Covers up to a 30-day supply (retail subscription); 31-90 day supply (mail prescription). If a dispensed drug has a chemically equivalent drug at a lowe

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
Out-of-Network Provider (You will pay the most) coinsurance coinsurance coinsurance Physician: coinsurance 50% Facility: coinsurance 50% Physician: coinsurance 50% Facility: coinsurance 50% retail copay/prescription, or Deductible does not apply. mail-order copay/ prescription Deductible does not apply. retail copay/prescription, or Deduct

What You Will Pay 50% 50% 50% $15 $38 $35 $88 $75 $188

Network Provider (You will pay the least) copay/visit $30 Deductible does not apply. copay/visit $60 Deductible does not apply. No charge Physician: No charge Facility: No charge Physician: coinsurance 0% Facility: coinsurance 0% $15 retail copay/prescription, or Deductible does not apply. $38 mail-order copay/ prescription Deductible does not apply. re

Services You May Need Primary care visit to treat an injury or illness Specialist visit Preventive care/screening/ immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) Tier 1 drugs Tier 2 drugs Tier 3 drugs

see a specialist? Common Medical Event If you visit a health care provider’soffice or clinic If you have a test If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.myallsavers.com