What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information $250 penalty for no out-of-network precertification. $250 penalty for no out-of-network precertification. $250 penalty if no precert of out-of- network non-routine services (i.e., partial hospitalization, etc.). Includes medical services for MH/SA diagnoses. $250 penalty for no out-of-network precertification. Includes medical services for MH/SA diagnoses. Primary Care or Specialist benefit levels apply for initial visit to confirm pregnancy. Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). $250 penalty for no out-of-network precertification. Coverage is limited to 60 visits annual max. (The limit is not applicable to mental health and substance use disorder conditions.)
Services You May Need
In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
Facility fee (e.g., hospital room) Physician/surgeon fees
20% coinsurance
40% coinsurance
If you have a hospital stay
20% coinsurance
40% coinsurance
$60 copay/office visit** 20% coinsurance/all other services **Deductible does not apply
40% coinsurance/office visit 40% coinsurance/all other services
Outpatient services
If you need mental health, behavioral health, or substance abuse services
Inpatient services
20% coinsurance
40% coinsurance
Office visits
20% coinsurance 20% coinsurance
40% coinsurance 40% coinsurance
Childbirth/delivery professional services
If you are pregnant
Childbirth/delivery facility services
20% coinsurance
40% coinsurance
If you need help recovering or have other special health needs
Home health care
20% coinsurance
40% coinsurance
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