What You Will Pay
Common Medical Event
Limitations, Exceptions, & Other Important Information
Non-Participating Provider (You will pay the most)
Services You May Need
Participating Provider (You will pay the least)
If you need mental health, behavioral health, or substance abuse services
Outpatient services
Office visits: No Charge (under age 19)/$15 copay/visit (age 19 & over)/20% coinsurance (all other outpatient)
50% coinsurance
Includes telemedicine.
Inpatient services
20% coinsurance
50% coinsurance
Preauthorization required. If you don't get preauthorization, non-participating provider benefits could be reduced by 50% of the total cost of the service. Preauthorization required for inpatient hospital stays in excess of 48 hrs. (vaginal delivery) or 96 hrs. (c-section). If you don't get preauthorization, non- participating provider benefits could be reduced by 50% of the total cost of the service. Cost sharing does not apply to preventive services from a participating provider. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Baby counts towards the mother’s expense. Limited to 60 visits per year. Preauthorization required. If you don't get preauthorization, non-participating provider benefits could be reduced by 50% of the total cost of the service. Physical, occupational, cognitive, respiratory/pulmonary therapy limited to 20 visits per each type of therapy per year. Post-cochlear implant aural therapy limited to 30 visits per year. Cardia rehab limited to 36 visits per year.
If you are pregnant
Office visits
No Charge ($15 copay for initial visit)
50% coinsurance
Childbirth/delivery professional services
20% coinsurance
50% coinsurance
Childbirth/delivery facility services
20% coinsurance
50% coinsurance
If you need help recovering or have other special health needs
Home health care
20% coinsurance
50% coinsurance
Rehabilitation services
$15 copay/visit
50% coinsurance
Habilitation services
$15 copay/visit
50% coinsurance
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