BCN (Retiree Faculty and Staff version) - MSU Human Resources

CommonMedical EventIf you haveoutpatientsurgeryIf you needimmediatemedicalattentionServices You May NeedFacility fee (e.g., ambulatorysurgery center)Physician/surgeon feesEmergency room servicesEmergency medicaltransportationUrgent careYour cost if you use aIn-Network Out-of-NetworkProviderProviderNo Charge after 20% co-insurance afterdeductibledeductibleLimitations & ExceptionsPrior authorization may be required/InNetwork weight reduction surgery 90%coinsurance after deductible up to $1000 permember; Out of Network – not covered/Infertility – 50% coinsurance after deductiblePrior authorization may be requiredNo Charge afterdeductible20% co-insurance afterdeductible$250 Co-pay $250 Co-pay Co-pay is waived if admitted or based onspecific signs and symptoms.20% co-insurance after 20% co-insurance after ---none---deductibledeductible$20 Co-pay per visit $20 Co-pay ---none---If you have ahospital stayFacility fee (e.g., hospital room)Physician/surgeon feeNo Charge afterdeductibleNo Charge afterdeductible20% co-insurance afterdeductible20% co-insurance afterdeductiblePrior authorization may be requiredPrior authorization may be requiredIf you havemental health,behavioralhealth, orsubstance abuseneedsIf you arepregnantMental/Behavioral healthoutpatient servicesMental/Behavioral healthinpatient servicesSubstance use disorder outpatientservicesSubstance use disorder inpatientservicesPrenatal and postnatal careDelivery and all inpatient servicesNo ChargeNo Charge afterdeductibleNo ChargeNo Charge afterdeductibleNo ChargeNo Charge afterdeductibleNo Charge afterdeductible20% co-insurance afterdeductible20% co-insurance afterdeductible20% co-insurance afterdeductible20% co-insurance afterdeductible20% co-insurance afterdeductiblePrior authorization may be requiredPrior authorization may be required/Additional days available beyond MedicarebenefitPrior authorization may be requiredPrior authorization may be requiredPrior authorization may be required for out ofnetwork care.Prior authorization may be required for out ofnetwork care3 of 8