Page 10 - QCHC.19 Employee Benefits
P. 10
Limitations, Exceptions, & Other
Important Information (20 visits per benefit period, combined with Alcoholism and Drug (30 days per benefit period, combined with Alcoholism and Drug (20 visits per benefit period, combined with Drug Abuse and Mental Health Services) (30 days per benefit period, combined with Drug Abuse and Mental Health Services; 1 admission per benefit period, combined with (20 visits per benefit period, combined with Alcoholism and Mental Health Services) (30 days per benefit period, combined with Alcoholism and Mental Health Services; 1 admission per benefit period, combined with Page 3 of 6 OHPSMP BE
None None None None None Abuse Services) Abuse Services) Drug Abuse) Alcoholism)
a Non-Network Provider (You will pay the most) $50 copay/visit, 40% $100 copay/visit, 40% 40% coinsurance 40% coinsurance $50 copay/visit, deductible; 40% coinsurance 40% coinsurance $50 copay/visit, deductible; 40% coinsurance 40% coinsurance $50 copay/visit, deductible; 40% coinsurance 40% coinsurance
What You Will Pay $200 copay/visit, 20% coinsurance coinsurance coinsurance
a Network Provider (You will pay the least) $50 copay/visit, 20% coinsurance $50 copay/visit 20% coinsurance 20% coinsurance $25 copay/visit, deductible, 20% coinsurance 20% coinsurance $25 copay/visit, deductible, 20% coinsurance 20% coinsurance $25 copay/visit, deductible, 20% coinsurance 20% coinsurance
Services You May Need Emergency room care Emergency medical transportation Urgent care Facility fee (e.g., hospital room) Physician/ surgeon fee (inpatient) Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services (alcoholism) Substance use disorder inpatient services (alcoholism) Substance use disorder outpatient services (drug use) Substance use disorder inpatient services (drug use)
Common Medical Event If you need immediate medical attention If you have a hospital stay If you need mental health, behavioral health, or substance abuse services
