Emergency room care 10% coinsurance Covered as In-Network --------none-------- If you need Emergency medical immediate 10% coinsurance 30% coinsurance --------none-------- transportation medical attention Urgent care 10% coinsurance 30% coinsurance --------none-------- Facility fee (e.g., hospital room) 10% coinsurance 30% coinsurance --------none-------- If you have a hospital stay Physician/surgeon fees 10% coinsurance 30% coinsurance --------none-------- Office Visit Office Visit Office Visit If you need 10% coinsurance 30% coinsurance --------none-------- Outpatient services mental health, Other Outpatient Other Outpatient Other Outpatient behavioral health, 10% coinsurance 30% coinsurance --------none-------- or substance $500 per admission penalty applies if abuse services Inpatient services 10% coinsurance 30% coinsurance pre-authorization is not obtained. Office visits 10% coinsurance 30% coinsurance Maternity care may include tests and services described elsewhere in the Childbirth/delivery professional 10% coinsurance 30% coinsurance SBC (i.e. ultrasound). services Your doctor’s charges for delivery are part of prenatal and postnatal care. Failure to obtain pre-authorization if If you are inpatient stay exceeds 48 hours for pregnant normal delivery and 96 hours after a Childbirth/delivery facility cesarean delivery may result in 10% coinsurance 30% coinsurance services or reduced benefits. $500 per admission penalty applies if pre-authorization is not obtained. Applies to inpatient facility. Other cost shares may apply depending on the services provided. Home health care 10% coinsurance 30% coinsurance 80 days limit/benefit period. If you need help Rehabilitation services 10% coinsurance 30% coinsurance *See Therapy Services section recovering or have Coverage is limited to 60 visits per other special calendar year for Cardiac Habilitation services 10% coinsurance 30% coinsurance health needs Rehabilitation, Occupational, Physical
If you need immediate medical attention Emergency room care 10% coinsurance Covered as In-Network --------none-------- Emergency medical transportation 10% coinsurance 30% coinsurance --------none-------- Urgent care 10% coinsurance 30% coinsurance --------none-------- If you have a hospital stay Facility fee (e.g., hospital room) 10% coinsurance 30% coinsurance --------none-------- Physician/surgeon fees 10% coinsurance 30% coinsurance --------none-------- If you need mental health, behavioral health, or substance abuse services Outpatient services Office Visit 10% coinsurance Other Outpatient 10% coinsurance Office Visit 30% coinsurance Other Outpatient 30% coinsurance Office Visit --------none-------- Other Outpatient --------none-------- Inpatient services 10% coinsurance 30% coinsurance $500 per admission penalty applies if pre-authorization is not obtained. If you are pregnant Office visits 10% coinsurance 30% coinsurance Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Your doctor’s charges for delivery are part of prenatal and postnatal care. Failure to obtain pre-authorization if inpatient stay exceeds 48 hours for normal delivery and 96 hours after a cesarean delivery may result in or reduced benefits. $500 per admission penalty applies if pre-authorization is not obtained. Applies to inpatient facility. Other cost shares may apply depending on the services provided. Childbirth/delivery professional services 10% coinsurance 30% coinsurance Childbirth/delivery facility services 10% coinsurance 30% coinsurance If you need help recovering or have other special health needs Home health care 10% coinsurance 30% coinsurance 80 days limit/benefit period. Rehabilitation services 10% coinsurance 30% coinsurance *See Therapy Services section Coverage is limited to 60 visits per calendar year for Cardiac Rehabilitation, Occupational, Physical Habilitation services 10% coinsurance 30% coinsurance
FINAL_Standard_Motor_Products_-_Medical_Plan_PPO_2018_(003).docx