Page 87 - Down East Wood Ducks 2022 Benefits Guide

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) Greater of 34-day supply or 100 units
to treat your illness Not covered retail pharmacy.
or condition $20 copay
(retail) Not covered Up to 90-day supply maintenance
More information Formulary Brand drugs $40 copay prescription drugs through mail order.
about prescription Non-Formulary Brand drugs (mail order)
drug coverage is
$30 copay
available at (retail)
$60 copay
1-800-701-2324. (mail order)

If you have Facility fee (e.g., ambulatory surgery center) $60 copay Not covered Precertification may be required.
(retail)
outpatient surgery Physician/surgeon fees $120 copay 40% coinsurance Combined network and out-of-network:
(mail order) 40% coinsurance No charge for second surgical opinion.
If you need Emergency room care 20% coinsurance Precertification may be required.
immediate medical 20% coinsurance 20% coinsurance
after $50 copay/visit Out-of-network: Not subject to
attention 20% coinsurance deductible.
after $50 copay/visit 20% coinsurance Copay waived if admitted as an
Emergency medical transportation 40% coinsurance inpatient.
20% coinsurance 40% coinsurance
If you have a Urgent care Out-of-network: Not subject to
hospital stay Facility fee (e.g., hospital room) $20 copay/visit 40% coinsurance deductible.
20% coinsurance
Physician/surgeon fee −−−−−−−−−−−none−−−−−−−−−−−
20% coinsurance
Out-of-network: Failure to precertify will
result in benefits payable being reduced
by $250.
Precertification may be required.

Combined network and out-of-network:
No charge for second surgical opinion.
Precertification may be required.

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