$25 per visit for office setting when performed by your designated PCP or network OB-Gyn physician, $40 when performed by other network providers. 35% Coinsurance per admission for ambulatory surgical facility, hospital outpatient department or surgical day care unit.
The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.
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