Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. Services (excluding emergency services) rendered by an out-of-network provider are not covered under this plan, with the exception of two (2) sessions per year for diagnosis/assessment by a licensed mental health provider.
This is the amount you’re responsible for when you have a procedure that does not require overnight hospitalization.