Page 5 - 3z.net.18 Employee Benefits

providers. a bill from a provider for the difference between the provider’s charge and what your plan
pays (balance billing). Be aware your network provider might use an out-of-network provider
for some services (such as lab work). Check with your provider before you get services.

Do you need a referral No. You can see the specialist you choose without a referral.
to see a specialist?

All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
What You Will Pay
Common Limitations, Exceptions, & Other
Services You May Need In-Network Provider Non-Network Provider
Medical Event Important Information
(You will pay the least) (You will pay the most)
Primary care visit to treat an $20/visit deductible does
40% coinsurance --------none--------
injury or illness not apply
$40/visit deductible does
If you visit a Specialist visit 40% coinsurance --------none--------
not apply
health care
You may have to pay for services that
provider’s office
aren't preventive. Ask your provider if
or clinic Preventive care/screening/
No charge 40% coinsurance the services needed are preventive.
immunization
Then check what your plan will pay
for.
Diagnostic test (x-ray, blood
No charge 40% coinsurance --------none--------
If you have a test work)
Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance --------none--------
$40/prescription or 50%
$10/prescription (retail
Tier 1 - Typically Generic coinsurance, whichever is
If you need drugs and home delivery)
to treat your greater (retail)
illness or Tier 2 - Typically Preferred / $25/prescription (retail) $40/prescription or 50%
condition Brand and $65/prescription coinsurance, whichever is
More information (home delivery) greater (retail)
about prescription Tier 3 - Typically Non-Preferred $40/prescription (retail) $40/prescription or 50% *See Prescription Drug section
drug coverage is / Specialty Drugs and $120/prescription coinsurance, whichever is
available at (home delivery) greater (retail)
http://www.anthe 25% coinsurance up to
m.com/pharmacyin $200/prescription (retail) $40/prescription or 50%
Tier 4 - Typically Specialty
formation/ (brand and generic) and 25% coinsurance up to coinsurance, whichever is
$200/prescription (home greater (retail)
delivery)
Facility fee (e.g., ambulatory
If you have 20% coinsurance 40% coinsurance --------none--------
surgery center)
outpatient surgery
Physician/surgeon fees 20% coinsurance 40% coinsurance --------none--------
* For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/fi.
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