Physician/surgeon fees 10% coinsurance 30% coinsurance None Emergency room care 10% coinsurance 10% coinsurance None If you need immediate Emergency medical 10% coinsurance 10% coinsurance Mileage limits apply. medical attention transportation Urgent care 10% coinsurance 30% coinsurance None Facility fee (e.g., hospital 10% coinsurance 30% coinsurance Preauthorization may be required. room) If you have a hospital stay Physician/surgeon fee 10% coinsurance 30% coinsurance None 30% coinsurance for Mental $20 copay/visit; deductible Outpatient services Health; 10% coinsurance for None If you need mental health, does not apply substance abuse behavioral health, or substance use disorder 30% coinsurance for Mental services Inpatient services 10% coinsurance Health; 10% coinsurance for Preauthorization is required. substance abuse Maternity care may include services described No charge; deductible does not elsewhere in the SBC (i.e. tests) and cost share Office visits 30% coinsurance apply may apply. Cost sharing does not apply to certain maternity services considered to be preventive. If you are pregnant Childbirth/delivery 10% coinsurance 30% coinsurance None professional services Childbirth/delivery facility 10% coinsurance 30% coinsurance None services Home health care 10% coinsurance 10% coinsurance None Physical, Occupational, Speech therapy is limited Rehabilitation services 10% coinsurance 30% coinsurance to a combined maximum of 60 visits per member, If you need help recovering per calendar year. or have other special health Treatment of Applied Behavioral Analysis (ABA) needs for Autism is limited through age 18. Physical, Habilitation services 10% coinsurance 30% coinsurance Occupational, and Speech Therapy limits are combined with Rehabilitation services limits.
Physician/surgeon fees 10% coinsurance 30% coinsurance None If you need immediate medical attention Emergency room care 10% coinsurance 10% coinsurance None Emergency medical transportation 10% coinsurance 10% coinsurance Mileage limits apply. Urgent care 10% coinsurance 30% coinsurance None If you have a hospital stay Facility fee (e.g., hospital room) 10% coinsurance 30% coinsurance Preauthorization may be required. Physician/surgeon fee 10% coinsurance 30% coinsurance None If you need mental health, behavioral health, or substance use disorder services Outpatient services $20 copay/visit; deductible does not apply 30% coinsurance for Mental Health; 10% coinsurance for substance abuse None Inpatient services 10% coinsurance 30% coinsurance for Mental Health; 10% coinsurance for substance abuse Preauthorization is required. If you are pregnant Office visits No charge; deductible does not apply 30% coinsurance Maternity care may include services described elsewhere in the SBC (i.e. tests) and cost share may apply. Cost sharing does not apply to certain maternity services considered to be preventive. Childbirth/delivery professional services 10% coinsurance 30% coinsurance None Childbirth/delivery facility services 10% coinsurance 30% coinsurance None If you need help recovering or have other special health needs Home health care 10% coinsurance 10% coinsurance None Rehabilitation services 10% coinsurance 30% coinsurance Physical, Occupational, Speech therapy is limited to a combined maximum of 60 visits per member, per calendar year. Habilitation services 10% coinsurance 30% coinsurance Treatment of Applied Behavioral Analysis (ABA) for Autism is limited through age 18. Physical, Occupational, and Speech Therapy limits are combined with Rehabilitation services limits.