Important Questions
Answers
Why This Matters:
Do you need a referral to see a specialist?
No.
You can see the specialist you choose without a referral .
All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
What You Will Pay
Out-of-Network Provider (You will pay the most)
Payment of all Out-Of-Network professional services will be limited to 135% of the Medicare fee schedule. Payment of all Out- Of-Network facility services will
Common Medical Event
Limitations, Exceptions, & Other Important Information
Network Provider (You will pay the least)
Services You May Need
be limited to 175% of the Medicare fee schedule
Does not include office surgery. Limited to general practice, family practice, OB/GYN, internal medicine, osteopaths, pediatricians, nurse practitioners, physician assistants, and mental health providers. Chiropractic coverage is limited to 30 visits. See Plan Document for other services. Does not include office surgery. See Plan Document for other services. Routine labs and x-rays are covered for out-of-network providers at no charge. You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
Primary care visit to treat an injury or illness
20% coinsurance
40% coinsurance
If you visit a health care provider’s office or clinic
Specialist visit
20% coinsurance
40% coinsurance
Preventive care/screening/ immunization
No charge, deductible does not apply
40% coinsurance
Diagnostic test (x-ray, blood work)
Does not include emergency room or urgent care diagnostic services.
If you have a test
20% coinsurance
40% coinsurance
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