Page 14 - Benefits Summary 2018-2019 b_Neat

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

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 Not covered None
injury or illness Deductible does not apply
$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** Not covered aren’t preventive. Ask your provider if
the services you need are preventive.
No charge/immunizations**
screening/immunization
**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
If you have a test $300 copay/scan at an outpatient
Imaging (CT/PET scans, facility** Not covered None
MRIs) $300 copay/scan in the office**
**Deductible does not apply

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