Page 43 - University of the South-2022-Benefit Guide REVISED 3.30.22 FSA WAIT PERIOD

What You Will Pay
Common Out-of-Network Limitations, Exceptions, & Other Important
Medical Event Services You May Need In-Network Provider Provider Information
(You will pay the least)
(You will pay the most)
$30 copay/visit
Primary care visit to treat deductible does not 40% coinsurance PhysicianNow - Powered by MDLIVE: $15
an injury or illness copay
apply.
$50 copay/visit
Specialist visit deductible does not 40% coinsurance Office surgery subject to office copay.
If you visit a health apply.
care provider’s
office or clinic A1c testing will be covered at 100%. You may
have to pay for services that aren’t
Preventive preventive. Ask your provider if the services
care/screening/ No Charge 40% coinsurance
immunization needed are preventive. Then check what your
plan will pay for. Travel immunization not
covered in office or clinic setting.
Diagnostic test (x-ray, No Charge 40% coinsurance Diagnostic testing benefits are determined by
blood work) place of service, such as office or ER.
If you have a test
Imaging (CT/PET scans, 20% coinsurance 40% coinsurance None
MRIs)
30 day supply for Retail Network; up to 90
$15 copay/prescription
Generic drugs deductible does not 40% coinsurance day supply for Home Delivery or Plus90
Network. 2 times Retail Copayment up to 90
apply.
day supply.
If you need drugs $50 copay/prescription 30 day supply for Retail Network; up to 90
to treat your Preferred brand drugs deductible does not 40% coinsurance day supply for Home Delivery or Plus90
illness or condition apply. Network. 2 times Retail Copayment up to 90
More information day supply. When a brand drug is chosen and
about prescription $75 copay/prescription a generic drug equivalent is available, you will
drug coverage is Non-preferred brand pay a penalty for the difference between the
available at drugs deductible does not 40% coinsurance cost of the brand drug and the generic drug,
www.bcbst.com/rxp apply. plus the generic drug copayment or
coinsurance.
$150 copay/prescription
Specialty drugs deductible does not Not Covered Up to a 30 day supply. Must use a pharmacy
in the Preferred Specialty Pharmacy Network.
apply.
Facility fee (e.g., Prior Authorization required for certain
ambulatory surgery 20% coinsurance 40% coinsurance outpatient procedures. Your cost share may
If you have center) increase to 50% if not obtained.
outpatient surgery Prior Authorization required for certain
Physician/surgeon fees 20% coinsurance 40% coinsurance outpatient procedures. Your cost share may
increase to 50% if not obtained.
$250 copay/visit $250 copay/visit
Emergency room care deductible does not deductible does not None
If you need apply. apply.
immediate medical Emergency medical 20% coinsurance 20% coinsurance None
attention transportation
$50 copay deductible
Urgent care 40% coinsurance Office surgery subject to office copay.
does not apply.

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