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
About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your charge, and many other factors. Focus on the amounts (, and ) and under the . Use this information to compare the portion of costs you might pay under different health . Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in-network pre-natal care and a hospital delivery) Managing Joe’s type 2 Diabetes (a year of routine in-network care of a condition) Mia’s Simple Fracture (in-network emergency room visit and follow up care) The overall $2,600 The overall $2,600 The overall $2,600 coinsurance 20% coinsurance 20% coinsurance 20% Hospital (facility) coinsurance 20% Hospital (facility) coinsurance 20% Hospital (facility) coinsurance 20% Other coinsurance 20% Other coinsurance 20% Other coinsurance 20% This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $1,900 In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay: Cost Sharing Cost Sharing Cost Sharing Deductibles $2,600 Deductibles $2,600 Deductibles $1,305 Copayments $0 Copayments $325 Copayments $0 Coinsurance $1,500 Coinsurance $240 Coinsurance $385 What isn’t covered What isn’t covered What isn’t covered Limits or exclusions $60 Limits or exclusions $55 Limits or exclusions $0 The total Peg would pay is $4,160 The total Joe would pay is $3,220 The total Mia would pay is $1,690