Page 118 - Tampa Bay Rays 2022 Flipbook

Will you pay less if Yes. See www.highmarkbcbs.com/find-a-doctor or call This plan uses a provider network. You will pay less if you use a provider in the plan’s
you use a network 1-800-701-2324 for a list of network providers. network. You will pay the most if you use an out-of-network provider, and you might
provider? receive a bill from a provider for the difference between the provider’s charge and
what your plan pays (balance billing).
Be aware your network provider might use an out-of-network provider for some
services (such as lab work). Check with your provider before you get services.
Do you need a referral No. You can see the specialist you choose without a referral.
to see a specialist?

All copayment and coinsurance costs shown in this chart are after your overall deductible has been met, if a deductible applies.

What You Will Pay

Common Medical Services You May Need Out-of-Network Limitations, Exceptions, & Other
Event Network Provider (You Provider (You will pay Important Information
will pay the least)
the most)
If you visit a health Primary care visit to treat an injury 30% coinsurance 50% coinsurance You may have to pay for services that aren’t
care provider’s office or illness preventive. Ask your provider if the services
or clinic Specialist visit 30% coinsurance 50% coinsurance needed are preventive. Then check what
Preventive No charge 50% coinsurance your plan will pay for.
care/screening/immunization Deductible does not apply.
Please refer to your preventive schedule for
additional information.
If you have a test Diagnostic test (x-ray, blood work) 30% coinsurance 50% coinsurance Precertification may be required.
Imaging (CT/PET scans, MRIs) 30% coinsurance 50% coinsurance Precertification may be required.
If you need drugs to Generic drugs 30% coinsurance Not covered Up to 31-day supply retail pharmacy.
treat your illness or (retail) Up to 90-day supply maintenance
condition 30% coinsurance prescription drugs through mail order.
(mail order)
More information about Brand drugs 30% coinsurance Not covered
prescription drug (retail)
coverage is available at 30% coinsurance
www.highmarkbcbs.com/ (mail order)
find-a-doctor/#/drug.
If you have outpatient Facility fee (e.g., ambulatory surgery 30% coinsurance 50% coinsurance Precertification may be required.
surgery center)
Physician/surgeon fees 30% coinsurance 50% coinsurance Precertification may be required.

2 of 9