What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information 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).
Services You May Need
In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
Office visits
20% coinsurance 20% coinsurance
50% coinsurance 50% coinsurance
Childbirth/delivery professional services
If you are pregnant
Childbirth/delivery facility services
20% coinsurance
50% coinsurance
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