Page 6 - 3z.net.18 Employee Benefits

What You Will Pay
Common Limitations, Exceptions, & Other
Services You May Need In-Network Provider Non-Network Provider
Medical Event Important Information
(You will pay the least) (You will pay the most)
$250/visit deductible does
not apply then 20%
Emergency room care Covered as In-Network Copay waived if admitted.
coinsurance deductible
If you need
does not apply
immediate
Emergency medical
medical attention 20% coinsurance Covered as In-Network --------none--------
transportation
$75/visit deductible does
Urgent care 40% coinsurance --------none--------
not apply
Physical medicine and rehabilitation
services (including day rehabilitation
If you have a Facility fee (e.g., hospital room) 20% coinsurance 40% coinsurance programs) are limited to 60 days of
hospital stay care regardless of the provider's
network status.
Physician/surgeon fees 20% coinsurance 40% coinsurance --------none--------
Office Visit
30 visits/benefit period for In-
Network Providers. 10 visits/benefit
period for Non-Network Providers.
If you need Office Visit
mental health, $40/visit deductible does Office Visit Mental/behavioral health visits count
40% coinsurance towards your substance abuse limit.
behavioral health, Outpatient services not apply
or substance Other Outpatient Other Outpatient Outpatient and Office services count
40% coinsurance towards the limit. Alcoholism
abuse services 20% coinsurance
outpatient (non-network) limited to 10
visits.
Other Outpatient
--------none--------

* For more information about limitations and exceptions, see plan or policy document at https://eoc.anthem.com/eocdps/fi.
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