Common Medical Event Services You May Need
Your cost if you use an In-
Network Provider
Your cost if you use an
Out-of-Network
Provider
Limitations & Exceptions
If you have a hospital stay
Facility fee (e.g., hospital room)
20%
coinsurance
20%
coinsurance
Bariatric/transplant services received at
any facility that is not an Institutes of
Quality or Excellence facility are not
covered. Precertification rules must be
followed or benefits are reduced by 50%,
up to a $1,000 maximum.
Physician/surgeon fee
20%
coinsurance
20%
coinsurance
If you have mental health,
behavioral health or
substance abuse needs
Mental/Behavioral health
outpatient services
20%
coinsurance
20%
coinsurance
––––––––––– None –––––––––––
Mental/Behavioral health
inpatient services
20%
coinsurance
20%
coinsurance
––––––––––– None –––––––––––
Substance use disorder
outpatient services
20%
coinsurance
20%
coinsurance
––––––––––– None –––––––––––
Substance use disorder inpatient
services
20%
coinsurance
20%
coinsurance
––––––––––– None –––––––––––
If you need help recovering or
have other special health
needs
Home health care
20%
coinsurance
20%
coinsurance
Covers up to 240 visits per calendar year
and includes Private Duty Nursing (in-
network and out-of-network visits
combined).
Rehabilitation services
20%
coinsurance
20%
coinsurance
––––––––––– None –––––––––––
Habilitation services
20%
coinsurance
20%
coinsurance
––––––––––– None –––––––––––
If you are pregnant
Prenatal and postnatal care
Prenatal: No charge;
Postnatal: 20%
coinsurance
Prenatal: No charge;
Postnatal: 20%
coinsurance
––––––––––– None –––––––––––
Delivery and all inpatient
services
20%
coinsurance
20%
coinsurance
––––––––––– None –––––––––––
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