| Will you pay less if you use a network provider? | Yes, See MedMutual.com/SBC or call 800-332-0741 for a list of participating providers. | This plan uses a provider network. You will pay less if you use a provider in the plan's network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider's charge and what your plan pays (balance billing). Be aware your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. |
| Do you need a referral to see a specialist? | No | You can see the specialist you choose without a referral. |
All coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Services with copayments are covered before you meet your deductible, unless otherwise specified.
| Common Medical Event | Services You May Need | What You Will Pay | Limitations, Exceptions, & Other Important Information | |
|---|---|---|---|---|
|
Network Provider (You will pay the least) |
Non-Network Provider (You will pay the most) |
|||
| If you visit a health care provider's office or clinic | Primary care visit to treat an injury or illness | No charge after deductible | 50% coinsurance | None |
| Specialist visit | No charge after deductible | 50% coinsurance | None | |
|
Preventive care/ screening/ immunization |
No charge | 50% coinsurance | You may have to pay for services that aren't preventive. Ask your provider if the services you need are preventive. Then check what your plan will pay for. | |
| If you have a test | Diagnostic test (x-ray) | No charge after deductible | 50% coinsurance | None |
| Diagnostic test (blood work) | No charge after deductible | 50% coinsurance | None | |
| Imaging (CT/PET scans, MRIs) | No charge after deductible | 50% coinsurance | None | |