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some services (such as lab work). Check with your provider before you get
services.
Do you need a Yes, written or oral approval is This plan will pay some or all of the costs to see a specialist for covered
referral to see a required, based upon medical services but only if you have a referral before you see the specialist.
specialist? policies.
GSU/4PZ
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Common What You Will Pay Limitations, Exceptions, & Other
Medical Event Services You May Participating Provider Non-Participating Important
Need (You will pay the Provider (You will pay Information
least) the most)
$30 copay / office visit
Primary care visit to and $5 copay / Virtual If you receive services in addition to
treat an injury or visits by a designated Not covered office visit, additional copayments or
illness virtual participating coinsurance may apply.
provider
Member is required to obtain a
referral to specialist or other licensed
health care practitioner, except for
OB/GYN Physician services,
If you visit a health reproductive health care services
care Specialist visit $60 copay / visit Not covered within the Participating Medical
office or clinic
Group and Emergency / Urgently
needed services. If you receive
services in addition to office visit,
additional copayments or
coinsurance may apply.
You may have to pay for services
Preventive
care/screening/ No charge Not covered provider if the services you need are
immunization
2 of 7
