Page 41 - Benefits Book Tanner Manor 2020
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Limitations, Exceptions & Other Important Information
&RSD\ applies 3ODQ Document for SODQ are subject to SURYLGHU if the SODQ ŘȱȱŜ
'HGXFWLEOH. to exam charge only. Does not include office surgery. FRVW VKDULQJ does not apply to SUHYHQWLYH VHUYLFHV. Any other preventive FRLQVXUDQFH. You may have to pay for SUHYHQWLYH. Ask your SUHYHQWLYH. Then check what your 3UHDXWKRUL]DWLRQ is required. If not received, a penalty will be When the retail store offers a lower price for generic, pay only the lower price. Covers up to a 30-day supply (retail prescription); 31-90 day supply (mail order
GHGXFWLEOH applies. &RSD\PHQW is not subject to any &RSD\ applies to exam charge only. See other services. As required under the ACA, identified clinical medicine services covered under your GHGXFWLEOH and services that aren't services needed are will pay for. None applied. prescription). prescription).
GHGXFWLEOH has been met, if a What You Will Pay 'HGXFWLEOH does not apply. FRSD\ mail order FRSD\ mail order FRSD\ mail order
FRLQVXUDQFH costs shown in this chart are after your
$40 FRSD\/visit, then covered at 100% FRSD\/visit, then covered at 100% $60 No charge. FRLQVXUDQFH 30% FRLQVXUDQFH 30% FRSD\ retail/$60 $20 FRSD\ retail/$150 $50 FRSD\ retail/$225 $75
Services You May Need Primary care visit to treat an injury or illness 6SHFLDOLVW visit 3UHYHQWLYH FDUH/VFUHHQLQJ/ immunization 'LDJQRVWLF WHVW (x-ray, blood Imaging (CT/PET scans, Generic drugs Preferred brand drugs Non-preferred brand drugs
FRSD\PHQW and work) MRIs)
All Common Medical Event If you visit a health SURYLGHU V office care or clinic If you have a test If you need drugs to treat your illness or condition More information SUHVFULSWLRQ about GUXJ FRYHUDJH is available at ZZZ P\&LJQD FRP
