pharmacy, you could be responsible for any differences between the covered expense and the actual non-participating providers/pharmacies charge. More information about prescription drug coverage is available at If you have Facility fee (e.g., ambulatory 20% coinsurance 20% coinsurance 40% coinsurance --------none-------- outpatient surgery center) surgery Physician/surgeon fees Not Applicable 20% coinsurance 40% coinsurance --------none-------- Covered as Emergency room care 20% coinsurance 20% coinsurance --------none-------- If you need immediate Emergency medical Covered as medical Not Applicable 20% coinsurance --------none-------- transportation attention Urgent care Not Applicable 20% coinsurance 40% coinsurance --------none-------- Inpatient requires authorization. You or your physician should call 1-800-392-1016. In an If you have a Facility fee (e.g., hospital room) 20% coinsurance 20% coinsurance 40% coinsurance emergency, seek care immediately hospital stay and call within 48 hours after admission. Physician/surgeon fees Not Applicable 20% coinsurance 40% coinsurance --------none-------- If you need Office Office Visit Office mental health, Outpatient 20% coinsurance 40% coinsurance --------none-------- Outpatient services behavioral 20% coinsurance Other Outpatient Other Outpatient Other Outpatient health, or 20% coinsurance 40% coinsurance --------none--------
More information about prescription drug coverage is available at pharmacy, you could be responsible for any differences between the covered expense and the actual non-participating providers/pharmacies charge. If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 20% coinsurance 20% coinsurance 40% coinsurance --------none-------- Physician/surgeon fees Not Applicable 20% coinsurance 40% coinsurance --------none-------- If you need immediate medical attention Emergency room care 20% coinsurance 20% coinsurance Covered as --------none-------- Emergency medical transportation Not Applicable 20% coinsurance Covered as --------none-------- Urgent care Not Applicable 20% coinsurance 40% coinsurance --------none-------- If you have a hospital stay Facility fee (e.g., hospital room) 20% coinsurance 20% coinsurance 40% coinsurance Inpatient requires authorization. You or your physician should call 1-800-392-1016. In an emergency, seek care immediately and call within 48 hours after admission. Physician/surgeon fees Not Applicable 20% coinsurance 40% coinsurance --------none-------- If you need mental health, behavioral health, or Outpatient services Outpatient 20% coinsurance Office 20% coinsurance Other Outpatient 20% coinsurance Office Visit 40% coinsurance Other Outpatient 40% coinsurance Office --------none-------- Other Outpatient --------none--------