Page 26 - USUI Benefit Book

2 of 8

Information Limitations, Exceptions, & Other Important preventive. Ask your provider if the services needed are preventive. Then check what your plan Preauthorization, step therapy and quantity limits may apply to select drugs. Preventive drugs covered in full. Mail order drugs are not covered

applies. None None will pay for. None May require preauthorization. out-of-network. None None

has been met, if a deductible Out-of-Network Provider (You will pay the most) $10 copay/prescription plus an additional 25% of BCBSM approved amount for the drug; deductible does not apply $30 copay/prescription plus an additional 25% of BCBSM approved amount for the drug; deductible does not apply $50 copay/prescription plus an additional 25% of BCBSM approved amount for the drug; deductible does not apply

What You Will Pay 40% coinsurance 40% coinsurance No charge; deductible does not 40% coinsurance 40% coinsurance 40% coinsurance 40% coinsurance 40% coinsurance

costs shown in this chart are after your deductible

In-Network Provider (You will pay the least) $30 copay/office visit; deductible does not apply $30 copay/visit; deductible does not apply apply 20% coinsurance 20% coinsurance $10 copay/prescription for retail 30-day supply, $10 copay/prescription for mail order 90-day supply; deductible does not apply $30 copay/prescription for retail 30-day supply, $60 copay/prescription for mail order 90-day supply; deductible does no

and coinsurance Services You May Need Primary care visit to treat an injury or illness Specialist visit Preventive care/ screening/ immunization Diagnostic test (x-ray, blood work) Imaging (CT/PET scans, MRIs) Generic or prescribed over-the-counter drugs Preferred brand-name drugs Non-Preferred brand- name drugs Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees

All copayment office or clinic prescription drug coverage

Common Medical Event If you visit a health care If you have a test If you need drugs to treat your illness or condition More information about is available at www.bcbsm.com/druglists If you have outpatient

surgery