What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information
Services You May Need
In-Network Provider (You will pay the least) $30 copay/office visit** $20 copay/MDLIVE visit** 20% coinsurance/all other services **Deductible does not apply
Out-of-Network Provider (You will pay the most) 50% coinsurance/office visit 50% coinsurance/all other services
If you need mental health, behavioral health, or substance abuse services
Outpatient services
None
Inpatient services
20% coinsurance 20% coinsurance 20% coinsurance
50% coinsurance 50% coinsurance 50% coinsurance
None
Office visits
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). Coverage is limited to 120 days annual max. 16 hour maximum per day (The limit is not applicable to mental health and substance use disorder conditions.) Coverage is limited to annual max of: 90 days for Rehabilitation services; 36 days for Cardiac rehab services; 20 days for Chiropractic care services Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies.
Childbirth/delivery professional services
If you are pregnant
Childbirth/delivery facility services
20% coinsurance
50% coinsurance
Home health care
20% coinsurance
50% coinsurance
If you need help recovering or have other special health needs
$30 copay/PCP visit** $40 copay/ Specialist visit** **Deductible does not apply
50% coinsurance/PCP visit 50% coinsurance/ Specialist visit
Rehabilitation services
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