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Health Fund

How The Special Features Of The PPO Plan And Low Option Plan Work

Special Rules for Using Certain Non-Network Providers at Network Facilities

When you receive treatment at a network facility and your treating physician (that is, the physician who ordered your treatment at the facility) is a network provider, any eligible services you receive from non-network anesthesiologists, radiologists, pathologists and emergency room physicians will be paid at the network percentage of the "Reasonable and Customary (R&C) limit." That means that once you have met the deductible, you will be responsible for the network coinsurance plus any amount over the R&C limit for each service.

However, if you go to a non-network facility, you may not take advantage of this special rule. That means you will be responsible for a higher percentage of the cost (the non-network coinsurance) and any amount over the R&C limit. Also, please see page 48 to find out what expenses and charges are covered for emergency care.

Managing Your Care
Filing Claims
Understanding Coordination Of Benefits (COB)