Page 15 - Benefits Summary 2018-2019

Important Questions Answers Why This Matters:
Do you need a referral to see
a specialist? No. You can see the specialist you choose without a referral.

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

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

Primary care visit to treat an $40 copay/visit
injury or illness Deductible does not apply Not covered None

$50 copay/visit
Specialist visit Not covered None
If you visit a health care Deductible does not apply

provider's office or clinic No charge/visit** You may have to pay for services that
Preventive care/ No charge/other services** aren’t preventive. Ask your provider if

screening/immunization No charge/immunizations** Not covered the services you need are preventive.
**Deductible does not apply Then check what your plan will pay
for.

Diagnostic test (x-ray, blood No charge Not covered None
work) Deductible does not apply

$300 copay/scan at an outpatient
If you have a test
Imaging (CT/PET scans, facility** Not covered None

MRIs) $300 copay/scan in the office**
**Deductible does not apply

2 of 8