What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information levels apply for initial visit to confirm pregnancy. Cost sharing does not apply for preventive services. Depending on the type of services, a copayment, coinsurance or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e., ultrasound). 50% penalty for no out-of-network precertification. Coverage is limited to 120 days annual max. 16 hour maximum per day (The limit is not applicable to mental health and substance use disorder conditions.) 50% penalty for failure to precertify out-of-network speech therapy services. Coverage is limited to annual max of: 90 days for Rehabilitation services; 36 days for Cardiac rehab services; 20 days for Chiropractic care services. Limits are not applicable to mental health conditions for Physical, Speech and Occupational therapies.
Services You May Need
In-Network Provider (You will pay the least)
Out-of-Network Provider (You will pay the most)
Childbirth/delivery professional services
20% coinsurance
50% coinsurance
Childbirth/delivery facility services
20% coinsurance
50% coinsurance
Home health care
20% coinsurance
50% coinsurance
If you need help recovering or have other special health needs
$30 copay/PCP visit** $40 copay/ Specialist visit** **Deductible does not apply
50% coinsurance/PCP visit 50% coinsurance/ Specialist visit
Rehabilitation services
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