Page 43 - 2023 Hickory Crawdads - Benefits Guide_Neat

Will you pay less if Yes. See www.highmarkbcbs.com/find-a-doctor or This plan uses a provider network. You will pay less if you use a provider in the
you use a network call 1-800-701-2324 for a list of network providers. plan’s network. You will pay the most if you use an out-of-network provider, and you
provider? might receive a bill from a provider for the difference between the provider’s charge
and what your plan pays (balance billing).
Be aware your network provider might use an out-of-network provider for some
services (such as lab work). Check with your provider before you get services.
Do you need a referral No. You can see the specialist you choose without a referral.
to see a specialist?

All copayment and coinsurance costs shown in this chart are after your overall deductible has been met, if a deductible applies.

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 visit a Primary care visit to treat an injury or $20 copay/visit 40% coinsurance You may have to pay for services that
health care illness Deductible does not apply. aren’t preventive. Ask your provider if
provider’s office Specialist visit $20 copay/visit 40% coinsurance the services needed are preventive.
or clinic Deductible does not apply. Then check what your plan will pay
Preventive care/screening/immunization No charge Not covered for.
Deductible does not apply. (preventive care visits)
No charge Please refer to your preventive
(screening services) schedule for additional information.
Deductible does not apply.
40% coinsurance
(immunizations)
Deductible does apply.
If you have a test Diagnostic test (x-ray, blood work) 20% coinsurance 40% coinsurance Precertification may be required.
Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance Precertification may be required.

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