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
Web:www.ProActPharmacyServices.com *See Plan Document for non-use of generic drug penalty.
Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees
Pre-notification is recommended for certain surgeries.
20% coinsurance
20% coinsurance 40% coinsurance
If you have outpatient surgery
20% coinsurance
20% coinsurance 40% coinsurance
None
$150 copay/visit, deductible does not apply 20% coinsurance, deductible does not apply $25 copay for services provided at Hughston Urgent Orthopedics; $60 copay all other urgent care visits, deductible does not apply
$150 copay/visit, deductible does not apply
Emergency room care
Copay waived if admitted to Hospital directly from Emergency Room.
Paid Same as Tier II
Pre-notification is recommended for elective (non-emergent) transportation by ambulance or medical van, and all transfers via air ambulance.
Emergency medical transportation
Paid Same as Tier I
Paid Same as Tier I
If you need immediate medical attention
$60 copay/visit, deductible does not apply
Urgent care
40% coinsurance
None
Facility fee (e.g., hospital room)
If you have a hospital stay
20% coinsurance
20% coinsurance 40% coinsurance
Pre-notification is recommended
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