20% Coinsurance 20% Coinsurance *Network deductible applies 20% Coinsurance 20% Coinsurance None If you need deductible does not apply deductible does not immediate medical If you receive services in addition to attention $55 Copay/visit 40% Coinsurance Urgent Care, additional copays, deductibles, or coinsurance may Prior Authorization required Facility fee (e.g., hospital 20% Coinsurance 40% Coinsurance If you have a room) hospital stay 20% Coinsurance 40% Coinsurance None Physician/surgeon fees Authorization required $45 40% Coinsurance Outpatient services If you need mental Prior Authorization required health, behavioral Neurobiological Disorders - health, or substance 20% Coinsurance 40% Coinsurance Pre-service notification is also required Inpatient services abuse services for Benefits provided for Applied Behavioral Analysis (ABA). $45 Copay/initial visit 40% Coinsurance Your cost in this category includes Office visits only physician delivery charges. Routine care is covered at No Charge. Childbirth/delivery 20% Coinsurance 40% Coinsurance If you are pregnant professional services Childbirth/delivery facility 20% Coinsurance 40% Coinsurance services Prior Authorization required If you need help 20% Coinsurance 40% Coinsurance recovering or have
If you need immediate medical attention 20% Coinsurance 20% Coinsurance *Network deductible applies 20% Coinsurance deductible does not apply 20% Coinsurance deductible does not None $55 Copay/visit 40% Coinsurance If you receive services in addition to Urgent Care, additional copays, deductibles, or coinsurance may If you have a hospital stay Facility fee (e.g., hospital room) 20% Coinsurance 40% Coinsurance Prior Authorization required Physician/surgeon fees 20% Coinsurance 40% Coinsurance None If you need mental health, behavioral health, or substance abuse services Outpatient services $45 40% Coinsurance Authorization required Inpatient services 20% Coinsurance 40% Coinsurance Prior Authorization required Neurobiological Disorders - Pre-service notification is also required for Benefits provided for Applied Behavioral Analysis (ABA). If you are pregnant Office visits $45 Copay/initial visit only 40% Coinsurance Your cost in this category includes physician delivery charges. Routine care is covered at No Charge. Childbirth/delivery professional services 20% Coinsurance 40% Coinsurance Childbirth/delivery facility services 20% Coinsurance 40% Coinsurance If you need help recovering or have 20% Coinsurance 40% Coinsurance Prior Authorization required