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
Physician/surgeon fees
20% coinsurance
20% coinsurance 40% coinsurance
None.
$25 copay/office visit, deductible does not apply, and 20% coinsurance for other outpatient services
$25 copay/office visit, deductible
If you need mental health, behavioral health, or substance abuse services
does not apply, and 20% coinsurance for other outpatient services
Outpatient services
40% coinsurance
None
Inpatient services 20% coinsurance
20% coinsurance 40% coinsurance
Pre-notification is recommended.
Cost sharing does not apply for preventive services. Depending on the type of services, a coinsurance may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). Pre-notification is recommended for vaginal deliveries requiring more than a 48 hour stay and for cesarean section deliveries requiring more than a 96 hour stay.
$25 copay/office visit, deductible does not apply
$25 copay/office visit, deductible does not apply
Office visits
40% coinsurance
Childbirth/delivery professional services
20% coinsurance
20% coinsurance 40% coinsurance
If you are pregnant
Childbirth/delivery facility services
20% coinsurance
20% coinsurance 40% coinsurance
If you need help recovering or have other special health needs
$25 copay/visit, deductible does not apply
$25 copay/visit, deductible does not apply
Pre-notification is recommended. Limited to 120 visits/calendar year
Home health care
40% coinsurance
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