Page 41 - 2020 Barrister Employee Benefits Book

Limitations, Exceptions & Other Important Information
Copay applies Plan Document for plan are subject to provider if the plan 2 of 6

Deductible. to exam charge only. Does not include office surgery. cost sharing does not apply to preventive services. Any other preventive coinsurance. You may have to pay for preventive. Ask your preventive. Then check what your Preauthorization 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

deductible applies. Copayment is not subject to any Copay applies to exam charge only. See other services. As required under the ACA, identified clinical medicine services covered under your deductible and services that aren't services needed are will pay for. None applied. prescription). prescription).

deductible has been met, if a What You Will Pay Deductible does not apply. copay mail order copay mail order copay mail order

coinsurance costs shown in this chart are after your

$40 copay/visit, then covered at 100% copay/visit, then covered at 100% $60 No charge. coinsurance 30% coinsurance 30% copay retail/$60 $20 copay retail/$150 $50 copay retail/$225 $75

Services You May Need Primary care visit to treat an injury or illness Specialist visit Preventive care/screening/ immunization Diagnostic test (x-ray, blood Imaging (CT/PET scans, Generic drugs Preferred brand drugs Non-preferred brand drugs

copayment and work) MRIs)

All Common Medical Event If you visit a health provider's office care or clinic If you have a test If you need drugs to treat your illness or condition More information prescription about drug coverage is available at www.myCigna.com