Laserfiche WebLink
<br /> <br /> <br /> 3 of 6 <br /> <br />Common <br />Medical Event <br />Services You May Need <br />What You Will Pay <br />Limitations, Exceptions, and Other Important <br />Information <br />Network Provider <br />(You will pay the <br />least) <br />Out-of-Network <br />Provider <br />(You will pay the <br />most) <br />If you need drugs to treat <br />your illness or condition <br />More information about <br />prescription drug coverage <br />is available at <br />healthpartners.com/preferredrx <br />Generic drugs <br /> <br />Formulary: 0% <br />coinsurance <br />Non-formulary: Not <br />covered <br /> <br />Formulary: 50% <br />coinsurance at retail, <br />mail not covered <br />Non-formulary: Not <br />covered at retail, mail <br />not covered <br />31 day supply retail / 93 day supply mail order. <br /> <br />Non-formulary drugs are not covered unless an <br />exception is granted. <br />Formulary insulin covered with no member cost - <br />sharing after a $25 benefit cap per prescription <br />per month. <br />Any amounts paid or reimbursed by a third party, <br />including but not limited to: point of service <br />rebates, manufacturer coupons, manufacturer <br />debit cards or other forms of direct <br />reimbursement to an insured for a product or <br />service, will not apply towards deductible and/or <br />out -of -pocket maximum. USPSTF A and B <br />recommended preventive drugs obtained with a <br />prescription, including OTC drugs, are covered <br />with no member cost sharing. <br />Formulary brand drugs 0% coinsurance 50% coinsurance at <br />retail, mail not covered <br />Non-formulary brand drugs Not covered Not covered at retail, <br />mail not covered <br />Specialty drugs 0% coinsurance Not covered <br />Specialty drugs are limited to drugs on the <br />specialty drug list and must be obtained from a <br />designated vendor. <br />If you have outpatient <br />surgery <br />Facility fee (e.g., <br />ambulatory surgery center) 0% coinsurance 50% coinsurance None <br />Physician/surgeon fees 0% coinsurance 50% coinsurance None <br />If you need immediate <br />medical attention <br />Emergency room care 0% coinsurance 0% coinsurance <br /> <br />Out-of -network services apply to the in-network <br />deductible. <br />Emergency medical <br />transportation 0% coinsurance 0% coinsurance Out-of -network services apply to the in-network <br />deductible. <br />Urgent care 0% coinsurance 0% coinsurance Out-of -Network services apply to the in-network <br />deductible. <br />If you have a hospital stay <br />Facility fee (e.g., hospital <br />room) 0% coinsurance 50% coinsurance None <br />Physician/surgeon fees 0% coinsurance 50% coinsurance None <br />Outpatient services 0% coinsurance 50% coinsurance None