Page 88 - Down East Wood Ducks 2022 Benefits Guide

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 Out-of-network: Failure to precertify will
health, or $20 copay/visit 40% coinsurance result in benefits payable being reduced
substance abuse Office visits by $250.
needs Childbirth/delivery professional services No charge 40% coinsurance Precertification may be required.
Childbirth/delivery facility services
If you are pregnant 20% coinsurance 40% coinsurance Cost sharing does not apply for
preventive services.
20% coinsurance 40% coinsurance Depending on the type of services, a
20% coinsurance 40% coinsurance 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.

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

Precertification may be required.

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