Your Cost If Your Cost Common You Use a If You Use Services You May Need Limitations & Exceptions Medical Event Network an Provider Pre-authorization required for Facility fee (e.g., hospital room) Preferred 10% 40% coinsurance after Provider coinsurance. All other care. calendar year deductible Facilities 20% If you have a coinsurance hospital stay Physician/surgeon fee Preferred 10% 40% coinsurance after None ––––––––––– ––––––––––– coinsurance. All other calendar year deductible Facility 20% coinsurance Mental/Behavioral health $30 per visit 40% coinsurance after None ––––––––––– ––––––––––– outpatient services calendar year deductible If you have mental Mental/Behavioral health 10% coinsurance 40% coinsurance after Pre-authorization required for health, behavioral inpatient services care. calendar year deductible health, or None Substance use disorder $30 copay per visit 40% coinsurance ––––––––––– ––––––––––– substance abuse outpatient services calendar year deductible needs Pre-authorization required for Substance use disorder 10% coinsurance 40% coinsurance after inpatient services care. calendar year deductible Prenatal and postnatal care No charge 40% coinsurance after None ––––––––––– ––––––––––– calendar year deductible If you are pregnant Delivery and all inpatient services 0% coinsurance 40% coinsurance after Includes outpatient postnatal care. Pre-authorization required for calendar year deductible out-of-network care.
Common Medical Event Services You May Need Your Cost If You Use a Network Provider Your Cost If You Use an Provider Limitations & Exceptions If you have a hospital stay Facility fee (e.g., hospital room) Preferred 10% coinsurance. All other Facilities 20% coinsurance 40% coinsurance after calendar year deductible Pre-authorization required for care. Physician/surgeon fee Preferred 10% coinsurance. All other Facility 20% coinsurance 40% coinsurance after calendar year deductible ––––––––––– None ––––––––––– If you have mental health, behavioral health, or substance abuse needs Mental/Behavioral health outpatient services $30 per visit 40% coinsurance after calendar year deductible ––––––––––– None ––––––––––– Mental/Behavioral health inpatient services 10% coinsurance 40% coinsurance after calendar year deductible Pre-authorization required for care. Substance use disorder outpatient services $30 copay per visit 40% coinsurance calendar year deductible ––––––––––– None ––––––––––– Substance use disorder inpatient services 10% coinsurance 40% coinsurance after calendar year deductible Pre-authorization required for care. If you are pregnant Prenatal and postnatal care No charge 40% coinsurance after calendar year deductible ––––––––––– None ––––––––––– Delivery and all inpatient services 0% coinsurance 40% coinsurance after calendar year deductible Includes outpatient postnatal care. Pre-authorization required for out-of-network care.