Page 24 - QCS.19 Employee Benefits
P. 24
Common Services You May Need Network Provi
Medical Event (You will pay the
$250 mail-order copa
If you have outpatient Facility fee (e.g., ambulatory prescription
surgery surgery center)
0% coinsurance
Physician/surgeon fees
Physician: $60 copay
Emergency room care Surgeon: 0% coinsu
Physician: 0% coins
Facility: $300 copa
0% coinsurance
If you need immediate Emergency medical 0% coinsurance
medical attention transportation
Urgent care Physician: $100 copa
Facility fee (e.g., hospital room) 0% coinsurance
Facility: $100 copa
0% coinsurance
0% coinsurance
If you have a hospital Physician: $60 cop
stay Physician/surgeon fees and 0% coinsuranc
Surgeon: 0% coinsu
If you need mental Outpatient services Physician: $60 copa
health, behavioral 0% coinsurance
health, or substance Inpatient services Facility: 0% coinsur
abuse services other outpatient servic
Office visits Physician: $60 copa
If you are pregnant Childbirth/delivery professional 0% coinsurance
services Facility: 0% coinsur
Childbirth/delivery facility $30 copay/visit and
0% coinsurance
0% coinsurance
0% coinsurance
* For more information about limitations and exceptions, see the plan or policydocu
