Page 114 - Trident 2022 Flipbook

What is not included in the Network: Premiums, balance-billed Even though you pay these expenses, they don't count toward the out-of-pocket limit.
out–of–pocket limit? charges, and health care this plan
doesn't cover do not apply to your out-
Will you pay less if you of-pocket.
use a network provider?
Out-of-network: Copayments, premiums, This plan uses a provider network. You will pay less if you use a provider in the plan’s
Do I need a referral to see a balance-billed charges, prescription drug network. You will pay the most if you use an out-of-network provider, and you might
specialist? expenses, and health care this plan receive a bill from a provider for the difference between the provider’s charge and
doesn't cover. what your plan pays (balance billing).
Yes. For a list of network providers, see Be aware your network provider might use an out-of-network provider for some
www.highmarkbcbs.com or call services (such as lab work). Check with your provider before you get services.
1-800-701-2324.
You can see the specialist you choose without a referral.
No.

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

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 visit a health Primary care visit to treat an injury or illness least) pay the most) You may have to pay for services that
$20 copay/visit 20% coinsurance aren’t preventive. Ask your provider if
care provider’s Specialist visit $20 copay/visit 20% coinsurance the services needed are preventive.
$20 copay for 20% coinsurance for Then check what your plan will pay for.
office or clinic Preventive care/Screening/Immunization preventive care visits preventive care visits
No charge for No charge for Out-of-network: Screening services not
If you have a test Diagnostic test (x-ray, blood work) screening services screening services subject to deductible.
Imaging (CT/PET scans, MRIs) No charge for 20% coinsurance for
immunizations immunizations Please refer to your preventive schedule
for additional information.
10% coinsurance 20% coinsurance Precertification may be required.
10% coinsurance 20% coinsurance Precertification may be required.

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