Page 20 - Benefits Summary 2018-2019

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)

$50 copay/office visit**
Outpatient services No charge/all other services** Not covered None
If you need mental health, **Deductible does not apply

behavioral health, or
substance abuse services $350 deductible/admission, plus
Inpatient services 30% coinsurance Not covered None
Deductible does not apply

Office visits 30% coinsurance Not covered Primary Care or Specialist benefit
Childbirth/delivery 30% coinsurance Not covered levels apply for initial visit to confirm
professional services pregnancy.

Depending on the type of services, a
If you are pregnant copayment, coinsurance or deductible

Childbirth/delivery facility $350 deductible/admission, plus Not covered may apply. Maternity care may
30% coinsurance
services include tests and services described
Deductible does not apply
elsewhere in the SBC (i.e.
ultrasound).

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