What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information 50% penalty for no out-of-network precertification. 50% penalty for no out-of-network precertification. Out-of-network services are paid at the in-network cost share and deductible. Out-of-network air ambulance services are paid at the in-network cost share and deductible.
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., ambulatory surgery center) Physician/surgeon fees
20% coinsurance
50% coinsurance
If you have outpatient surgery
20% coinsurance
50% coinsurance
20% coinsurance No charge/ x- ray, blood work and Imaging(MRI/CAT/PET)** **Deductible does not apply No charge Deductible does not apply $50 copay/visit Deductible does not apply
20% coinsurance No charge/ x- ray, blood work and Imaging(MRI/CAT/PET)** **Deductible does not apply No charge Deductible does not apply $50 copay/visit Deductible does not apply
Emergency room care
If you need immediate medical attention
Emergency medical transportation
Urgent care
None
Facility fee (e.g., hospital room) Physician/surgeon fees
50% penalty for no out-of-network precertification. 50% penalty for no out-of-network precertification. 50% penalty if no precert of out-of- network non-routine services. Includes medical services for MH/SA diagnoses. 50% 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.
20% coinsurance
50% coinsurance
If you have a hospital stay
20% coinsurance
50% coinsurance
$30 copay/office visit** $20 copay/MDLIVE visit** 20% coinsurance/all other services **Deductible does not apply
50% coinsurance/office visit 50% coinsurance/all other services
Outpatient services
If you need mental health, behavioral health, or substance abuse services
Inpatient services
20% coinsurance
50% coinsurance
Office visits
20% coinsurance 20% coinsurance
50% coinsurance 50% coinsurance
If you are pregnant
Childbirth/delivery professional services
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