Summary of Benefits Coverage

You will pay the most if you use an out-of-network provider, and you use a network provider? or call 1-800-776-4672 for a list of network might receive a bill from a provider for the difference between the provider’s charge providers. [...] Common Medical Services You May Need What You Will Pay Limitations, Exceptions, & Other Event Network Provider Out-of-Network Provider Important Information (You will pay the least) (You will pay the most) Primary care visit to treat an injury or illness No charge No charge ---none--- Specialist visit No charge No charge ---none--- Other practitioner office visit: Physical and Occupational Service. [...] care provider’s Psychologist No charge No charge ---none--- office or clinic Nurse Practitioner No charge No charge ---none--- Preventive care (Well Child No charge; deductible does not No charge; deductible does not Age and frequency limitations may Physician Visit) apply apply apply. [...] Urgent care No charge No charge ---none--- Facility fee (e.g., hospital room) No charge No charge ---none--- If you have a Physician Visits No charge No charge ---none--- hospital stay Surgeon fee No charge (cutting) No charge (cutting) ---none--- No charge (non-cutting) No charge (non-cutting) ---none--- Outpatient services If you have mental Physician services No charge No charge ---none--- heal. [...] No charge (DME) No charge (DME) No charge No charge Services may require preauthorization.