Page 115 - Trident 2022 Flipbook

What You Will Pay

Common Medical Services You May Need Network Provider Out-of-Network Limitations, Exceptions, and Other
Event (You will pay the Provider (You will Important Information

If you need drugs Generic drugs least) pay the most) Up to 34-day supply or 100 units retail
to treat your illness Not covered pharmacy.
or condition 20% coinsurance Up to 90-day supply maintenance
$10 minimum/$100 Not covered prescription drugs through mail order.
More information maximum copay .
about prescription copay 20% coinsurance
drug coverage is (retail) 20% coinsurance Precertification may be required.
available at 20% coinsurance $200 copay/visit Precertification may be required.
1-800-701-2324. $20 minimum/$200 Out-of-network: Not subject to
maximum copay deductible.
Formulary Brand drugs copay Copay waived if admitted as an
(mail order) inpatient.
If you have Facility fee (e.g., ambulatory surgery center) −−−−−−−−−−−none−−−−−−−−−−−
outpatient surgery Physician/surgeon fees 20% coinsurance −−−−−−−−−−−none−−−−−−−−−−−
Emergency room care $10 minimum/$100 Precertification may be required.
If you need maximum copay Out-of-network: Failure to precertify will
immediate medical (retail) result in benefits payable being reduced
attention 20% coinsurance by $250.
$20 minimum/$200 Precertification may be required.
maximum copay
(mail order)
10% coinsurance

10% coinsurance

$200 copay/visit

If you have a Emergency medical transportation 10% coinsurance 20% coinsurance
hospital stay Urgent care $20 copay/visit 20% coinsurance
Facility fee (e.g., hospital room) 10% coinsurance 20% coinsurance

Physician/surgeon fee 10% coinsurance 20% coinsurance

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