CLINICAL RESOURCES 2017 BENEFIT GUIDE

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Common
What You Will Pay
Limitations, Exceptions, & Other Important
Medical Event
Services You May Need
Network Provider
(You will pay the least)
Non-Network Provider(You will pay the most)
Information
Specialty Drugs
35% coinsurance;deductible does notapply
35% coinsurance;deductible does not apply
25% coinsurance when filled via a preferrednetwork specialty pharmacyPreauthorization may be required - if notobtained, penalty will be 100% for certainprescription drugs
If you have outpatientsurgery
Facility fee (e.g., ambulatorysurgery center)
$2350 copay/visit;deductible does notapply
30% coinsurance
Preauthorization may be required - if notobtained, penalty will be 40%
Physician/surgeon fees
No charge; deductibledoes not apply
30% coinsurance
None
If you need immediatemedical attention
Emergency room care
$850 copay/visit;deductible does notapply
$850 copay/visit;deductible does not apply
Emergency room care:Copayment waived if admitted
Emergency medicaltransportation
$850 copay/transport;deductible does notapply
$850 copay/transport;deductible does not apply
Urgent care
$125 copay/visit;deductible does notapply
30% coinsurance
If you have a hospitalstay
Facility fee (e.g., hospitalroom)
$2350 copay/day;deductible does notapply
30% coinsurance
3 days for copay per dayPreauthorization may be required - if notobtained, penalty will be 40%
Physician/surgeon fees
No charge; deductibledoes not apply
30% coinsurance
None
If you need mentalhealth, behavioralhealth, or substanceabuse services
Outpatient services
$55 copay/visit;deductible does notapply
30% coinsurance
Inpatient services:3 days for
copay per day
Preauthorization may be required - if notobtained, penalty will be 40%
Inpatient services
$2350 copay/day;deductible does notapply
30% coinsurance
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