Important Questions
Answers
Why This Matters:
This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out- of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of- network provider for some services (such as lab work). Check with your provider before you get services.
Yes. See www.alliedbenefit.com or call 1-312-906-8080 for a list of network providers.
Will you pay less if you use a network provider?
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
Tier III (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 be limited to 175% of the Medicare fee schedule
Tier I Provider -All Hughston entities (You will pay the least)
Common Medical Event
Services You May Need
Limitations, Exceptions, & Other Important Information
Tier II (Network) Provider
Copay applies to exam charge only. 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.
$25 copay/office visit, deductible does not apply, and 20% coinsurance for other outpatient services
$25 copay/office visit, deductible
If you visit a health care provider’s office or clinic
Primary care visit to treat an injury or illness
does not apply, and 20% coinsurance for other outpatient services
40% coinsurance
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