Page 109 - Tampa Bay Rays 2022 Flipbook

Will you pay less if Yes. See www.highmarkbcbs.com/find-a-doctor or call This plan uses a provider network. You will pay less if you use a provider in the
you use a network 1-800-701-2324 for a list of network providers. plan’s network. You will pay the most if you use an out-of-network provider, and you
provider? might receive a bill from a provider for the difference between the provider’s charge
and what your plan pays (balance billing).
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.
Do you need a referral No. You can see the specialist you choose without a referral.
to see a specialist?

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 Limitations, Exceptions, & Other
Medical Event Services You May Need Network Provider (You Out-of-Network Provider Important Information
will pay the least) (You will pay the most)
If you visit a Primary care visit to treat an injury or illness $15 copay/visit 40% coinsurance You may have to pay for services that
health care Deductible does not apply. aren’t preventive. Ask your provider if
provider’s Specialist visit $15 copay/visit 40% coinsurance the services needed are preventive.
office or clinic Deductible does not apply. Then check what your plan will pay for.
Preventive care/screening/immunization No charge Not covered for preventive
Deductible does not apply. care visits Please refer to your preventive schedule
40% coinsurance for for additional information.
screening services and
immunizations
If you have a Diagnostic test (x-ray, blood work) 20% coinsurance 40% coinsurance Precertification may be required.
test Imaging (CT/PET scans, MRIs) 20% coinsurance 40% coinsurance Precertification may be required.

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