Page 32 - Touching All the Bases- Power point 2023 Umpires_Neat

What You Will Pay
Common Medical Services You May Need Limitations, Exceptions, & Other
Event Network Provider (You Out-of-Network Provider Important Information
will pay the least) (You will pay the most)
If you need drugs Generic drugs $10 copay/prescription Not covered Up to 31-day supply retail pharmacy.
to treat your (retail) Up to 90-day supply maintenance
illness or $20 copay/prescription prescription drugs through mail order.
condition (mail order)
Formulary Brand drugs $35 copay/prescription Not covered
More information (retail)
about prescription $70 copay/prescription
drug coverage is (mail order)
available at Non-Formulary Brand drugs $60 copay/prescription Not covered
www.highmarkbcbs. (retail)
com/find-a- $120 copay/prescription
doctor/#/drug. (mail order)

If you have Facility fee (e.g., ambulatory surgery No charge 30% coinsurance Precertification may be required.
outpatient surgery center)
Physician/surgeon fees No charge 30% coinsurance Precertification may be required.
If you need Emergency room care $100 copay/visit $100 copay/visit Copay waived if admitted as an
immediate medical Deductible does not apply. inpatient.
attention Emergency medical transportation No charge No charge −−−−−−−−−−−none−−−−−−−−−−−
Deductible does not apply.
Urgent care $30 copay/visit 30% coinsurance The Copayment, if any, does not
apply to Urgent Care Services
prescribed for the treatment of Mental
Health or Substance Abuse.
If you have a Facility fees (e.g., hospital room) No charge 30% coinsurance Precertification may be required.
hospital stay Out-of-network: Failure to precertify
will result in benefits payable being
reduced by $1,000.
Physician/surgeon fees No charge 30% coinsurance Precertification may be required.

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