Coverage notice

Individual and Family Plans Pharmacy Transparency In Coverage Notice

Last Revised: October 10, 2023

This notice contains important information about the cost estimate and information on the amount you may ultimately be required to pay for this item or service. Read this notice carefully along with the cost estimate. You may need to request a new cost estimate as you obtain new information, such as information on additional items or services you will receive as part of your diagnosis, treatment or procedure.

Key terms

• An allowed amount is the maximum amount your benefit plan will pay for a covered item or service furnished by an out-of-network provider.
• Cost sharing is your share of costs for a covered item or service that you must pay (sometimes called “out-of-pocket costs”). Some examples of cost sharing are deductibles, coinsurance and copayments. This term doesn’t include other costs you may be responsible for, such as premiums, balance billed amounts for out-of-network providers or the cost of services not covered by your benefit plan.
• A covered item or service is an item or service that your benefit plan will pay, either in whole or in part, under the terms of your benefit plan.
• An out-of-network provider is a provider that doesn’t have a contract with your plan to provide services at pre-negotiated rates.
• Prerequisites are certain requirements your benefit plan may impose on you or your provider so that it can determine whether a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary before it will provide benefits for related items and services. Prerequisites include Prior Authorization, Concurrent Review, and Step Therapy or Fail First requirements.

Other common medical and insurance terms, including definitions of deductibles, coinsurance and copayments, can be found in the Department of Labor’s Uniform Glossary of Coverage and Medical Terms.

Important information about your cost estimate

This cost estimate is designed to provide you with information about the cost of an item or service before you receive care. However, this cost estimate has certain limitations that you should consider before making any decision to obtain the item or service.

The actual charges for the items and services may be different from those described in this cost estimate, depending on the actual care you receive. For example, if your physician provides additional services during your visit, your charges could be more than the cost estimate. This is one reason why it’s important to discuss with your provider both before and during your visit which items and services you’ll receive and to request a new cost estimate if new information becomes available.

If you’re treated by an out-of-network provider, after paying the cost-sharing amount determined by your benefit plan, you may still receive a bill for the difference between the amount the out-of-network provider charges for the item or service and the amount paid by your benefit plan. This is called balance billing, and this amount is not included in your cost estimate.

This calculation doesn’t include copayment assistance, other third-party payments or any other costs you may be responsible for, such as premiums.

This cost estimate isn’t a benefit determination or guarantee that coverage will be provided for the items and services for which you requested information. For example, your benefit plan may need to determine whether the item or service is medically necessary in your case before making a payment. You should follow your benefit plan’s process for filing a claim for benefits and contact your benefit plan to help determine if there are any additional requirements that apply to you as part of that process.