Do you need a referral No. You can see the specialist you choose without a referral. to see a specialist? All and costs shown in this chart are after your has been met, if a applies. What You Will Pay Common Limitations, Exceptions, & Other Services You May Need 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 $50/visit medical 50% coinsurance --------none-------- injury or illness deductible does not apply $50/visit medical Specialist visit 50% coinsurance --------none-------- deductible does not apply If you visit a Immunizations through age 5: No health care charge for Out-of-Network Providers. provider’s office You may have to pay for services that or clinic Preventive care/screening/ No charge 50% coinsurance aren't preventive. Ask your provider if immunization the services needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, blood 30% coinsurance 50% coinsurance --------none-------- work) If you have a test Imaging (CT/PET scans, MRIs) 30% coinsurance 50% coinsurance --------none-------- 20% coinsurance Prescription Drug $45/prescription or 50% deductible does not apply coinsurance, (retail) and whichever is greater, If you need drugs Tier 1 - Typically Generic $40/prescription Prescription Drug to treat your Prescription Drug deductible does not apply illness or deductible does not apply (retail) condition (home delivery) More information about prescription 30% coinsurance, drug coverage is Prescription Drug *See Prescription Drug section available at or deductible applies (retail) Tier 2 - Typically Preferred / contact RxBenefits’ and $80/prescription, Not Covered Brand Member Services Prescription Drug Department at 1- deductible applies (home delivery) 40% coinsurance, Tier 3 - Typically Non-Preferred Prescription Drug $45/prescription or 50% / Specialty Drugs deductible applies (retail) coinsurance, and $120/prescription,
Do you need a referral to see a specialist? No. You can see the specialist you choose without a referral. All and costs shown in this chart are after your has been met, if a applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Non-Network Provider (You will pay the most) If you visit a health care provider’s office or clinic Primary care visit to treat an injury or illness $50/visit medical deductible does not apply 50% coinsurance --------none-------- Specialist visit $50/visit medical deductible does not apply 50% coinsurance --------none-------- Preventive care/screening/ immunization No charge 50% coinsurance Immunizations through age 5: No charge for Out-of-Network Providers. You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) 30% coinsurance 50% coinsurance --------none-------- Imaging (CT/PET scans, MRIs) 30% coinsurance 50% coinsurance --------none-------- If you need drugs to treat your illness or condition More information about prescription drug coverage is available at or contact RxBenefits’ Member Services Department at Tier 1 - Typically Generic 20% coinsurance Prescription Drug deductible does not apply (retail) and $40/prescription Prescription Drug deductible does not apply (home delivery) $45/prescription or 50% coinsurance, whichever is greater, Prescription Drug deductible does not apply (retail) *See Prescription Drug section Tier 2 - Typically Preferred / Brand 30% coinsurance, Prescription Drug deductible applies (retail) and $80/prescription, Prescription Drug deductible applies (home delivery) Not Covered Tier 3 - Typically Non-Preferred / Specialty Drugs 40% coinsurance, Prescription Drug deductible applies (retail) and $120/prescription, $45/prescription or 50% coinsurance, 1-
2019-Low-Option-PPO_Final.docx