Page 105 - Trident 2022 Flipbook
P. 105
What You Will Pay
Common Medical Services You May Need Network Provider Out-of-Network Limitations, Exceptions, and Other
Event (You will pay the Provider (You will Important Information
If you need Emergency room care least) pay the most) Out-of-network: Subject to network
deductible.
30% coinsurance 30% coinsurance Coinsurance waived if admitted as an
inpatient.
immediate medical Out-of-network: Subject to network
deductible.
attention −−−−−−−−−−−none−−−−−−−−−−−
Emergency medical transportation 30% coinsurance 30% coinsurance Precertification may be required.
Out-of-network: Failure to precertify will
If you have a Urgent care 30% coinsurance 50% coinsurance result in benefits payable being reduced
hospital stay Facility fee (e.g., hospital room) 30% coinsurance 50% coinsurance by $250.
Precertification may be required.
Physician/surgeon fee 30% coinsurance 50% coinsurance
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