Page 173 - 2021 Miami Marlins Front Office Benefits Guide

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 have a test Diagnostic test (x-ray, blood work) 10% coinsurance 30% coinsurance Precertification may be required.
Imaging (CT/PET scans, MRIs) 10% coinsurance 30% coinsurance Precertification may be required.
If you need drugs Generic drugs $10 copay/prescription Not covered Up to 31-day supply retail pharmacy.
to treat your illness (retail) Up to 90-day supply maintenance
or condition $20 copay/prescription prescription drugs through mail order.
(mail order)
More information Deductible does not apply.
about prescription Formulary Brand drugs $20 copay/prescription Not covered
drug coverage is (retail)
available at $40 copay/prescription
www.highmarkbcbs. (mail order)
com/find-a- Deductible does not apply.
doctor/#/drug. Non-Formulary Brand drugs $35 copay/prescription Not covered
(retail)
$70 copay/prescription
(mail order)
Deductible does not apply.
If you have Facility fee (e.g., ambulatory surgery 10% coinsurance 30% coinsurance Precertification may be required.
outpatient surgery center)
Physician/surgeon fees 10% coinsurance 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. Deductible does not apply. inpatient.
attention Emergency medical transportation 10% coinsurance 10% coinsurance −−−−−−−−−−−none−−−−−−−−−−−
Deductible does not apply. Deductible does not apply.
Urgent care $15 copay/visit 30% coinsurance −−−−−−−−−−−none−−−−−−−−−−−
Deductible does not apply.
If you have a Facility fees (e.g., hospital room) 10% coinsurance 30% coinsurance Precertification may be required.
hospital stay Physician/surgeon fees 10% coinsurance 30% coinsurance Precertification may be required.

3 of 9