What You Will Pay Participating Provider Non-Participating Common Limitations, Exceptions & Other Important Services You May Need (You will pay the Provider Medical Event Information (You will pay the most) Penalty of $700 for failure to obtain /stay, apply If you have a hospital 50% Facility fee (e.g., hospital room) for out-of-network care. stay None 50% Physician/surgeon fees No charge None Office & other outpatient Office & other outpatient If you need mental services: $25 /visit, services: 50% Outpatient services health, behavioral doesn't apply health, or substance Penalty of $700 for failure to obtain /stay, doesn't apply services 50% Inpatient services for out-of-network care. doesn't apply to certain 50% , apply Office visits No charge . Maternity care may include & services described elsewhere in /pregnancy, doesn't If you are pregnant 50% Childbirth/delivery professional services the SBC (i.e. ultrasound). Penalty of $700 for apply failure to obtain for /stay, doesn't apply out-of-network care may apply. 50% Childbirth/delivery facility services Penalty of $700 for failure to obtain 50% No charge for out-of-network care. Limited to treatment for 60 consecutive days/condition for Physical, Occupational & 50% No charge Speech Therapy combined. Limited to children up to age 21 for Autism. 50% No charge If you need help 180 days in-& 240 days out-of-network recovering or have per calendar year. Penalty of $700 for failure to other special health 50% No charge obtain for out-of-network needs care. Limited to 1 for same/similar purpose. Excludes repairs for 50% No charge misuse/abuse. Penalty of $700 for failure to obtain No charge 50% for out-of-network care.
Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions & Other Important Information Participating Provider (You will pay the Non-Participating Provider (You will pay the most) If you have a hospital stay Facility fee (e.g., hospital room) /stay, apply 50% Penalty of $700 for failure to obtain for out-of-network care. Physician/surgeon fees No charge 50% None If you need mental health, behavioral health, or substance services Outpatient services Office & other outpatient services: $25 /visit, doesn't apply Office & other outpatient services: 50% None Inpatient services /stay, doesn't apply 50% Penalty of $700 for failure to obtain for out-of-network care. If you are pregnant Office visits No charge 50% , apply doesn't apply to certain . Maternity care may Childbirth/delivery professional services /pregnancy, doesn't apply 50% include & services described elsewhere in the SBC (i.e. ultrasound). Penalty of $700 for failure to obtain for out-of-network care may apply. Childbirth/delivery facility services /stay, doesn't apply 50% If you need help recovering or have other special health needs No charge 50% Penalty of $700 for failure to obtain for out-of-network care. No charge 50% Limited to treatment for 60 consecutive days/condition for Physical, Occupational & Speech Therapy combined. No charge 50% Limited to children up to age 21 for Autism. No charge 50% 180 days in-& 240 days out-of-network per calendar year. Penalty of $700 for failure to obtain for out-of-network care. No charge 50% Limited to 1 for same/similar purpose. Excludes repairs for misuse/abuse. No charge 50% Penalty of $700 for failure to obtain for out-of-network care.