Facility fee (e.g., 20% Coinsurance 40% Coinsurance None If you have ambulatory surgery outpatient surgery center) 20% Coinsurance 40% Coinsurance None Physician/surgeon fees 20% Coinsurance 20% Coinsurance *Network deductible applies If you need immediate medical 20% Coinsurance 20% Coinsurance *Network deductible applies attention 20% Coinsurance 40% Coinsurance None 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 Prior Authorization required 20% Coinsurance 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 services for Benefits provided for Applied Behavioral Analysis (ABA). 20% Coinsurance 40% Coinsurance Your cost in this category includes Office visits physician delivery charges. Routine Childbirth/delivery 20% Coinsurance 40% Coinsurance If you are pregnant professional services care is covered at No Charge. Childbirth/delivery facility 20% Coinsurance 40% Coinsurance services Prior Authorization required If you need help 20% Coinsurance 40% Coinsurance recovering or have
If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) 20% Coinsurance 40% Coinsurance None Physician/surgeon fees 20% Coinsurance 40% Coinsurance None If you need immediate medical attention 20% Coinsurance 20% Coinsurance *Network deductible applies 20% Coinsurance 20% Coinsurance *Network deductible applies 20% Coinsurance 40% Coinsurance None 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 services Outpatient services 20% Coinsurance 40% Coinsurance Prior 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 20% Coinsurance 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
HSA2018SBC.docx