Page 99 - QCS.19 SPD - PPO
P. 99

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/visit          get Prior Authorization, benefits could be
 Physician/surgeon fees  Physician: 50% coinsurance
 deductible does not apply                    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/visit
           Physician: 50% coinsurance
 Urgent care  deductible does not apply

 Facility: $100 copay/visit                   One copay is applied per network urgent
           Facility: 50% coinsurance
 deductible does not apply                    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/visit
 Physician/surgeon fees  Physician: 50% coinsurance  reduced by 50% of the total cost of the
 deductible does not apply
                                              service.

 Surgeon: 0% coinsurance  Surgeon: 50% coinsurance

 Physician: $60 copay/visit  Physician: 50% coinsurance

 Outpatient services  deductible does not apply

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

 If you need mental  other outpatient services

 health, behavioral  Physician: $60 copay/visit  Physician: 50% coinsurance
 health or substance  Inpatient services  deductible does not apply  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.










                                                                                   Page 3 of 7
   94   95   96   97   98   99   100   101   102   103   104