What You Will Pay Participating Provider Non-Participating Common Limitations, Exceptions & Other Important Services You May Need (You will pay the least) Provider Medical Event Information (You will pay the most) None $15 /visit, doesn't apply Primary care visit to treat an injury or 50% illness None /visit, doesn't apply If you visit a health 50% care office or clinic You may have to pay for services that aren't . Ask your if the services needed are / / immunization 50% , doesn't apply No charge preventive. Then check what your will pay for. None (x-ray, blood work) 50% No charge If you have a test None 50% Imaging (CT/PET MRIs) No charge If you need drugs to 30% Generic drugs to pharmacy plan for limitations treat your illness or 30% to pharmacy plan for limitations Preferred brand drugs condition 30% Non-preferred brand drugs Refer to pharmacy plan for limitations Please contact CVS for Please contact CVS for Please contact CVS for more information More information about more information more information regarding specialty prescriptions is available from CVS regarding specialty regarding specialty Caremark at or prescriptions prescriptions None No charge Facility fee (e.g., ambulatory surgery If you have outpatient 50% center) surgery None 50% Physician/surgeon fees No charge None $100 /visit, doesn't $100 /visit, doesn't apply apply If you need immediate 50% for non-emergency transport No charge No charge medical attention out-of-network. None /visit, doesn't apply 50%
Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) If you visit a health care office or clinic Primary care visit to treat an injury or illness $15 /visit, doesn't apply 50% None /visit, doesn't apply 50% None / / immunization No charge 50% , doesn't apply You may have to pay for services that aren't . Ask your if the services needed are preventive. Then check what your will pay for. If you have a test (x-ray, blood work) No charge 50% None Imaging (CT/PET MRIs) No charge 50% None If you need drugs to treat your illness or condition More information about is available from CVS Caremark at or Generic drugs 30% to pharmacy plan for limitations Preferred brand drugs 30% to pharmacy plan for limitations Non-preferred brand drugs 30% Refer to pharmacy plan for limitations Please contact CVS for more information regarding specialty prescriptions Please contact CVS for more information regarding specialty prescriptions Please contact CVS for more information regarding specialty prescriptions If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 50% None Physician/surgeon fees No charge 50% None If you need immediate medical attention $100 /visit, doesn't apply $100 /visit, doesn't apply None No charge No charge 50% for non-emergency transport out-of-network. /visit, doesn't apply 50% None
BMCS%20POS%20w-%20RX%202017%20SBC.docx