Page 99 - QCS.19 SPD - HSA

What You Will Pay
Common Limitations, Exceptions, & Other
Services You May Need Network Provider Out-of-Network Provider
Medical Event Important Information
(You will pay the least) (You will pay the most)

Facility fee (e.g., ambulatory
0% coinsurance 50% coinsurance
If you have outpatient surgery center) Prior Authorization is required. If you don't

surgery Physician: $60 copay/0% get Prior Authorization, benefits could be
Physician/surgeon fees Physician: 50% coinsurance
coinsurance reduced by 50% of the total cost of the

Surgeon: 0% coinsurance Surgeon: 50% coinsurance service.

Emergency room services Physician: 0% coinsurance Physician: 0% coinsurance*
Facility: $300 copay/0% Facility: $300 copay/0%

coinsurance coinsurance* *Out-of-Network emergency services are
If you need immediate Emergency medical covered at the network benefit level.
0% coinsurance 0% coinsurance*
medical attention transportation
Physician: $100 copay/0% Physician: 50% coinsurance

Urgent care coinsurance
Facility: $100 copay/0% One copay is applied per network urgent
Facility: 50% coinsurance
coinsurance care visit.
If you have a Facility fee (e.g., hospital room) 0% coinsurance 50% coinsurance Prior Authorization is required. If you don't

hospital stay get Prior Authorization, benefits could be
Physician: $60 copay/0%
Physician/surgeon fees Physician: 50% coinsurance reduced by 50% of the total cost of the
coinsurance
service.

Surgeon: 0% coinsurance Surgeon: 50% coinsurance

Physician: $60 copay/0% Physician: 50% coinsurance
Outpatient services coinsurance

Facility: 0% coinsurance for Facility: 50% coinsurance None

If you need mental other outpatient services
health, behavioral Physician: $60 copay/0% Physician: 50% coinsurance
health or substance Inpatient services coinsurance Prior Authorization is required. If you don't

abuse services. get Prior Authorization, benefits could be
Facility: 0% coinsurance Facility: 50% coinsurance reduced by 50% of the total cost of the
service.

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