Prior Authorization required 20% Coinsurance 40% Coinsurance (x-ray, blood work) for Sleep Studies. If you have a test Advance Notification required Imaging (CT/PET scans, 20% Coinsurance 40% Coinsurance MRIs) Provider means pharmacy for purposes Retail & Mail Order for of this section. 1-30 day supply: $5 Copay Retail: Up to a 30 and 90 day supply Tier 1 Retail & Mail Order for Retail: $5 Mail-Order: Up to a 90 day supply 31-90 day supply: $10 You may need to obtain certain Copay including certain specialty drugs, from a Retail & Mail Order for pharmacy designated by us. Certain 1-30 day supply: $40 drugs may have a pre-authorization Tier 2 Copay Retail: $40 Copay requirement or may result in a higher Retail & Mail for If you need drugs to cost. If you use a non-network pharmacy day supply: $80 Copay treat your illness or (including a mail order pharmacy), you Retail & Mail for condition are responsible for any amount over the 30 day supply: $60 Copay More information allowed amount. You may be required to Tier 3 Retail & Mail Order for Retail: $60 Copay about is available at use a lower-cost drug(s) prior to benefits 31-90 day supply: $120 www.myuhc.com under your policy being available for Copay certain prescribed drugs. Tier 1 contraceptives covered at No Charge. See the website listed for information on drugs covered by your plan. Not all Retail: N/A Tier 4 Retail: N/A drugs are covered. Prescription Out of Mail Order: N/A Pocket limit: $2,250 Individual / $4,500 Family. Prescription drugs to the prescription drug out-of pocket-limit. Facility fee (e.g., 20% Coinsurance 40% Coinsurance None If you have ambulatory surgery outpatient surgery center) 20% Coinsurance 40% Coinsurance None Physician/surgeon fees
If you have a test (x-ray, blood work) 20% Coinsurance 40% Coinsurance Prior Authorization required for Sleep Studies. Imaging (CT/PET scans, MRIs) 20% Coinsurance 40% Coinsurance Advance Notification required If you need drugs to treat your illness or condition More information about is available at www.myuhc.com Tier 1 Retail & Mail Order for 1-30 day supply: $5 Copay Retail & Mail Order for 31-90 day supply: $10 Copay Retail: $5 Provider means pharmacy for purposes of this section. Retail: Up to a 30 and 90 day supply Mail-Order: Up to a 90 day supply You may need to obtain certain including certain specialty drugs, from a pharmacy designated by us. Certain drugs may have a pre-authorization requirement or may result in a higher cost. If you use a non-network pharmacy (including a mail order pharmacy), you are responsible for any amount over the allowed amount. You may be required to use a lower-cost drug(s) prior to benefits under your policy being available for certain prescribed drugs. Tier 1 contraceptives covered at No Charge. See the website listed for information on drugs covered by your plan. Not all drugs are covered. Prescription Out of Pocket limit: $2,250 Individual / $4,500 Family. Prescription drugs to the prescription drug out-of pocket-limit. Tier 2 Retail & Mail Order for 1-30 day supply: $40 Copay Retail & Mail for day supply: $80 Copay Retail: $40 Copay Tier 3 Retail & Mail for day supply: $60 Copay Retail & Mail Order for 31-90 day supply: $120 Copay Retail: $60 Copay Tier 4 Retail: N/A Mail Order: N/A Retail: N/A If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 20% Coinsurance 40% Coinsurance None Physician/surgeon fees 20% Coinsurance 40% Coinsurance None 30
RegularStateofNE2018SBC.docx