Page 94 - Trident 2022 Flipbook

Will you pay less if you Yes. For a list of network providers, see This plan uses a provider network. You will pay less if you use a provider in the plan’s
use a network provider? www.highmarkbcbs.com or call network. You will pay the most if you use an out-of-network provider, and you might
1-800-701-2324. receive a bill from a provider for the difference between the provider’s charge and
Do I need a referral to see a what your plan pays (balance billing).
specialist? No. Be aware your network provider might use an out-of-network provider for some
services (such as lab work). Check with your provider before you get services.

You can see the specialist you choose without a referral.

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% coinsurance 40% coinsurance aren’t preventive. Ask your provider if
care provider’s Specialist visit 20% coinsurance 40% coinsurance the services needed are preventive.
Then check what your plan will pay for.
office or clinic Preventive care/Screening/Immunization No charge for 40% coinsurance for
preventive care preventive care Out-of-network: Immunizations not
services services subject to deductible.

If you have a test Diagnostic test (x-ray, blood work) 20% coinsurance 40% coinsurance Please refer to your preventive schedule
Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance for additional information.
Precertification may be required.

Precertification may be required.

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