Page 3 of 7 QP250021_L * For more information about limitations and exceptions, see the plan or policy document at www.phpni.com. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Brand non-formulary drugs (Tier 4) No coinsurance after deductible Specialty drugs 30% coinsurance after deductible Covers up to a 30 day supply, except when manufacturer’s packaging further limits the supply. Preauthorization is required to prevent claim denial. Only Office Administered Specialty Drugs are covered Out-of-Network. (Tier 1 - Preferred Specialty drugs) Tier 1 – No coinsurance after deductible (Tier 2 - Specialty drugs) Tier 2 – No coinsurance after deductible If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No coinsurance after deductible 30% coinsurance after deductible For coverage for specific outpatient services, preauthorization is required to prevent claim denial. Physician/surgeon fees No coinsurance after deductible 30% coinsurance after deductible If you need immediate medical attention Emergency room care No coinsurance after deductible No coinsurance after deductible ER diagnosis must be emergent in nature. Emergency medical transportation No coinsurance after deductible No coinsurance after deductible Ambulance is always paid at the in-network benefit however, non-contracted providers may bill you for charges that exceed our payment amount. Urgent care No coinsurance after deductible 30% coinsurance after deductible Services received within Service Area must be received at a network provider to be covered as network benefits. If you have a hospital stay Facility fee (e.g., hospital room) No coinsurance after deductible 30% coinsurance after deductible Preauthorization is required to prevent claim denial. Physician/surgeon fees If you need mental health, behavioral health, or substance abuse services Outpatient services No coinsurance after deductible 30% coinsurance after deductible Intensive Outpatient/Partial Hospitalization: Preauthorization is required to prevent claim denial. Inpatient Services: Preauthorization is required to prevent claim denial. Inpatient services No coinsurance after deductible 30% coinsurance after deductible