Common Medical Event
Services You May
Need
Your cost if you use
an APN and/or
Aexcel Network
Provider
If you have outpatient surgery
Physician/surgeon fees
20%
coinsurance
APN/Aexcel network not
applicable
If you have a hospital stay
If you need immediate
medical attention
Emergency room
services
Emergency medical
transportation
Urgent care
Facility fee (e.g.,
hospital room)
20%
coinsurance
Physician/surgeon fee
20%
coinsurance
If you have mental health,
behavioral health or
substance abuse needs
Mental/Behavioral
health outpatient
Mental/Behavioral
health inpatient
Substance use disorder
outpatient services
Substance use disorder
inpatient services
APN/Aexcel network not
applicable
APN/Aexcel network not
applicable
APN/Aexcel network not
applicable
APN/Aexcel network not
applicable
APN/Aexcel network not
applicable
APN/Aexcel network not
applicable
20% coinsurance if you are
not in an Aexcel or APN
network;
40% coinsurance if you are in
an Aexcel/APN network
20%
coinsurance
20%
coinsurance
Your cost if you use an
In-Network Provider
20% coinsurance if you are
not in an Aexcel or APN
network;
40% co-insurance if you are
in an Aexcel/APN network
20%
coinsurance
20%
coinsurance
20%
coinsurance
20%
coinsurance
20%
coinsurance
50%
coinsurance
20%
coinsurance
50%
coinsurance
50%
coinsurance
50%
coinsurance
50%
coinsurance
50%
coinsurance
50%
coinsurance
Non emergency use not covered.
Non emergency use not covered.
Bariatric/transplant services received at
any facility that is not an Institutes of
Quality or Excellence facility are not
covered; APN/Aexcel does not apply.
Precertification rules must be followed or
benefits are reduced by 50%, up to a
$1,000 maximum.
––––––––––– None –––––––––––
––––––––––– None –––––––––––
––––––––––– None –––––––––––
––––––––––– None –––––––––––
Limitations & Exceptions
Bariatric/transplant services received at
any facility that is not an Institutes of
Quality or Excellence facility are not
covered; APN/Aexcel does not apply.
Precertification rules must be followed or
benefits are reduced by 50%, up to a
$1,000 maximum.
20%
coinsurance
50%
coinsurance
––––––––––– None –––––––––––
Your cost if
you use an
Out-of-
Network
Provider
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