Page 44 - 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** 30% coinsurance/office visit $250 penalty if no precert of non-
Outpatient services No charge/all other services** 30% coinsurance/all other routine services (i.e., partial
If you need mental health, **Deductible does not apply services hospitalization, IOP, etc.).

behavioral health, or
substance abuse services $300 deductible/admission $600 deductible/admission,
Inpatient services plus 30% coinsurance $250 penalty for no precertification.
Deductible does not apply
Deductible does not apply

Office visits No charge 30% coinsurance Primary Care or Specialist benefit
Childbirth/delivery No charge 30% coinsurance 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 $300 deductible/admission $600 deductible/admission, may apply. Maternity care may
plus 30% coinsurance
services Deductible does not apply include tests and services described
Deductible does not apply
elsewhere in the SBC (i.e.
ultrasound).

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