2020 SBC HRA Plan_Mid-America Apartments_3332254_01.01.2020

What You Will Pay

Common Medical Event

Limitations, Exceptions, & Other Important Information 50% penalty if no precert of non- routine services (i.e., partial hospitalization, IOP, etc.). 50% penalty for no precertification. Primary Care or Specialist benefit levels apply for initial visit to confirm pregnancy. 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) $30 copay/office 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

Inpatient services

20% coinsurance 20% coinsurance 20% coinsurance

50% coinsurance 50% coinsurance 50% coinsurance

Office visits

Childbirth/delivery professional services

If you are pregnant

Childbirth/delivery facility services

20% coinsurance

50% coinsurance

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