Page 3 of 8 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information In-Network (You will pay the least) Out-of-Network (You will pay the most) If you have a test Diagnostic test (x-ray, blood work) No charge 20% coinsurance Deductible applies first; pre- authorization may be required Imaging (CT/PET scans, MRIs) No charge 20% coinsurance Deductible applies first; pre- authorization may be required If you need drugs to treat your illness or condition More information about prescription drug coverage is available at bluecrossma.org/medicatio n Generic drugs $15 / retail supply or $30 / mail service supply $30 / retail supply and all charges for mail service Up to 30-day retail (90-day mail service) supply; cost share may be waived, reduced, or increased for certain covered drugs and supplies; pre-authorization required for certain drugs Preferred brand drugs $30 / retail supply or $60 / mail service supply $60 / retail supply and all charges for mail service Non-preferred brand drugs $50 / retail supply or $150 / mail service supply $100 / retail supply and all charges for mail service Specialty drugs Applicable cost share (generic, preferred, non-preferred) Not covered When obtained from a designated specialty pharmacy; cost share may be waived, reduced, or increased for certain covered drugs and supplies; pre-authorization required for certain drugs If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge 20% coinsurance Deductible applies first; pre- authorization required for certain services Physician/surgeon fees No charge 20% coinsurance Deductible applies first; pre- authorization required for certain services If you need immediate medical attention Emergency room care No charge No charge Deductible applies first Emergency medical transportation No charge No charge Deductible applies first Urgent care $40 / visit 20% coinsurance Deductible applies first; a telehealth cost share may be applicable