Page 235 - Washington Nationals 2023 Benefits Guide -10.26.22_Neat

What You Will Pay
Common Medical Services You May Need Limitations, Exceptions, & Other
Event Network Provider (You Out-of-Network Provider Important Information
will pay the least) (You will pay the most)
If you need mental Outpatient services $20 copay/visit 20% coinsurance Precertification may be required.
health, behavioral Deductible does not apply.
health, or Inpatient services No charge 20% coinsurance Precertification may be required.
substance abuse Deductible does not apply. Out-of-network: Failure to precertify will
services result in benefits payable being
reduced by $250.
If you are pregnant Office visits 10% coinsurance 20% coinsurance Cost sharing does not apply for
Childbirth/delivery professional 10% coinsurance 20% coinsurance preventive services.
services Depending on the type of services, a
Childbirth/delivery facility services 10% coinsurance 20% coinsurance copayment, coinsurance, or deductible
may apply.
Maternity care may include tests and
services described elsewhere in the
SBC (i.e. ultrasound.)
Network: The first visit to determine
pregnancy is covered at no charge.
Please refer to the Women’s Health
Preventive Schedule for additional
information.
Precertification may be required.
Out-of-network: Failure to precertify will
result in benefits payable being
reduced by $250.

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