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 have outpatient surgery
Facility fee (e.g., ambulatory surgery center)
20% coinsurance
50% coinsurance
Preauthorization required for certain surgeries. If you don't get preauthorization, non-participating provider benefits could be reduced by 50% of the total cost of the service. See your plan document for a detailed listing. Non-participating providers paid at the participating provider level of benefits. Non-participating providers paid at the participating provider level of benefits for emergency services for ground & air ambulance and non-emergency services for air ambulance.
Physician/surgeon fees
20% coinsurance
50% coinsurance
If you need immediate medical attention
Emergency room care
20% coinsurance
20% coinsurance
Emergency medical transportation
20% coinsurance (emergency & non- emergency services- ground & air)
20% coinsurance (emergency services – ground & air)/ 20% coinsurance (non-
emergency services - air)/50% coinsurance (non-emergency services – ground)
Urgent care
20% coinsurance 20% coinsurance
50% coinsurance 50% coinsurance
----------------none----------------
If you have a hospital stay
Facility fee (e.g., hospital room) Physician/surgeon fees
Preauthorization required. If you don't get preauthorization, non-participating providers benefits could be reduced by 50% of the total cost of the service.
20% coinsurance
50% coinsurance
If you need mental health, behavioral health, or substance abuse services
Outpatient services
20% coinsurance
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
If you are pregnant
Office visits
20% coinsurance
50% coinsurance
Childbirth/delivery professional services
20% coinsurance
50% coinsurance
Childbirth/delivery facility services
20% coinsurance
50% coinsurance
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