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Common
Medical Event
Services You May Need
Your Cost If
You Use a
Network
Provider
Your Cost if
You Use a
Non-Network
Provider
Limitations & Exceptions
If you need
immediate medical
attention
Emergency room services
$250 copay/visit $250 copay/visit Copayment waived if admitted
Emergency medical
transportation
No charge after
deductible
No charge after
deductible
none
Urgent care
$100 copay/visit 30% coinsurance none
If you have a hospital
stay
Facility fee (e.g., hospital room) No charge after
deductible
30% coinsurance Preauthorization may be required - if not obtained,
penalty will be 40%
Physician/surgeon fee
No charge after
deductible
30% coinsurance none
If you have mental
health, behavioral
health, or substance
abuse needs
Mental/Behavioral health
outpatient services
$30 copay/visit
30% coinsurance none
Mental/Behavioral health
inpatient services
No charge after
deductible
30% coinsurance Preauthorization may be required - if not obtained,
penalty will be 40%
Substance use disorder
outpatient services
$30 copay/visit
30% coinsurance none
Substance use disorder
inpatient services
No charge after
deductible
30% coinsurance Preauthorization may be required - if not obtained,
penalty will be 40%
If you are pregnant
Prenatal and postnatal care
No charge after
deductible
30% coinsurance none
Delivery and all inpatient
services
No charge after
deductible
30% coinsurance Preauthorization may be required - if not obtained,
penalty will be 40%
If you need help
recovering or have
other special health
needs
Home health care
No charge after
deductible
30% coinsurance 120 visit limit per cal yr
Preauthorization may be required - if not obtained,
penalty will be 40%
Rehabilitation services
$65 copay/visit
30% coinsurance Therapies:
Preauthorization may be required - if not obtained,
penalty will be 40%
Manipulations and Therapies:
40 visits per cal yr/plan yr, includes manipulations,
adjustments
For non-network, 10 visit per cal yr/plan yr, includes
manipulations, adjustments
Habilitation services
$65 copay/visit
30% coinsurance