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* For more information about limitations and exceptions, see the plan or policy document at www.HorizonBlue.com/members.3 of 8Common Medical Event Services You May Need What You Will PayLimitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider(You will pay the most) Prime Therapeutics LLC (Prime) Service Center www.MyPrime.com or 1-800-370-5088. Non-preferred brand drugs $75.00 Copayment/Retail. $200.00 Copayment/Mail Order. Deductible does not apply. $70.00 Copayment/Retail. $200.00 Copayment/Mail Order. Specialty drugs Covered at retail benefit in above applicable categories. Covered at retail benefit in above applicable categories.If you haveoutpatient surgeryFacility fee (e.g., ambulatory surgery center) 20% Coinsurance for Outpatient Hospital, Ambulatory Surgical Center. Not Covered. Procedures related to spine surgery are subject to pre-service and post-service utilization management review. 20% Physician/surgeon fees 20% Coinsurance for Coinsurance for anesthesia. Outpatient Hospital, Ambulatory Surgical Center. Not Covered.If you needimmediate medicalattentionEmergency room care $100.00 Copayment per visit for Outpatient Hospital and 20% Coinsurance. Deductible does not apply. $100.00 Copayment per visit for Outpatient Hospital and 20% Coinsurance. Deductible does not apply. Copayment waived if admitted within 24 hours. Out-of-network payment at the innetwork level of benefits applies only to true medical emergencies and accidental injuries. Emergency medical transportation 20% Coinsurance. Not Covered. __________none__________Urgent care $40.00 Copayment per visit for Specialist. Deductible does not apply. Not Covered. __________none__________If you have ahospital stayFacility fee (e.g., hospital room) 20% Coinsurance for Inpatient Hospital. Not Covered. Requires pre-approval; 20% penalty applies for non-compliance. In-network inpatient separation period is limited to 90 days. Physician/surgeon fees 20% Coinsurance for Inpatient Hospital. Not Covered. 20% Coinsurance for anesthesia. If you need mentalhealth, behavioralhealth, or substanceabuse servicesOutpatient services 20% Coinsurance for Outpatient Hospital. Not Covered. __________none__________Inpatient services 20% Coinsurance for Inpatient Hospital. Not Covered. Requires pre-approval; 20% penalty applies for non-compliance. In-network inpatient separation period is limited to 90 days. 28