Page 3 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Tier 1 Tier 2 Tier 3 Important Information If you need drugs to treat your illness or condition. More information about prescription drug coverage is available at https://www.tru escripts.com/m embers Generic drugs (Tier 1) Benefits are applied by outside vendor Benefits are applied by outside vendor Benefits are applied by outside vendor None Preferred brand drugs (Tier 2) Benefits are applied by outside vendor Benefits are applied by outside vendor Benefits are applied by outside vendor Non-preferred brand drugs (Tier 3) Benefits are applied by outside vendor Benefits are applied by outside vendor Benefits are applied by outside vendor Specialty drugs (Tier 4) Benefits are applied by outside vendor Benefits are applied by outside vendor Benefits are applied by outside vendor If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 10% coinsurance 20% coinsurance 50% coinsurance Preauthorization is required. Physician/surgeon 10% coinsurance 20% coinsurance 50% coinsurance fees If you need immediate medical attention Emergency room care $250 copay per visit; 10% coinsurance $250 copay per visit; 10% coinsurance $250 copay per visit; 10% coinsurance Tier 1 deductible applies to Tier 2 & Tier 3 benefits; Copay may be waived if admitted Emergency medical 10% coinsurance 10% coinsurance 10% coinsurance transportation Tier 1 deductible applies to Tier 2 & Tier 3 benefits; Preauthorization is required for Non-emergent Air services. Urgent care 10% coinsurance 20% coinsurance 50% Coinsurance None