Page 116 - Trident 2022 Flipbook

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 have mental Outpatient services least) pay the most) Precertification may be required.
health, behavioral Inpatient services $20 copay/visit 20% coinsurance Out-of-network: Failure to precertify will
health, or result in benefits payable being reduced
substance abuse Office visits 10% coinsurance 20% coinsurance by $250.
needs Childbirth/delivery professional services Precertification may be required.
Childbirth/delivery facility services 10% coinsurance 20% coinsurance
If you are pregnant 10% coinsurance 20% coinsurance Cost sharing does not apply for
10% coinsurance 20% coinsurance preventive services.
Depending on the type of services, a
copayment, coinsurance, or deductible
may apply.
Maternity care may include tests and
services described elsewhere in the
SBC (i.e. ultrasound.)

Network: The first visit to determine
pregnancy is covered at no charge.
Please refer to the Women’s Health
Preventive Schedule for additional
information.

Precertification may be required.
Out-of-network: Failure to precertify will
result in benefits payable being reduced
by $250.

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