Individual $500 Family $1,000. Individual $2,000. Family $4,000. $125 Copay per visit. 20% Coinsurance after Deductible

Transcription

1 Schedule of Benefits Plus $500 Plan This Schedule is part of Your Certificate of Coverage (COC) but does not replace it. Many words are defined elsewhere in the COC, and other limitations or exclusions may be listed in other sections of Your COC. Reading this Schedule by itself could give You an inaccurate impression of the terms of Your Coverage. This Schedule must be read with the rest of Your COC. Benefits Annual Total amount a Member or family is required to pay each calendar year before benefits are payable. Charges that exceed the Out-of- Network Rate do not count toward satisfying the. The Annual need only be met once per calendar year. Annual Out-of-Pocket Maximum Only Coinsurance applies to the Out-of-Pocket Maximum. s, Copayments, and charges that exceed the Out-of-Network Rate do not apply. Maximum Lifetime Benefit Combined total of all benefits. Office Visits Primary Care Provider Services include, but are not limited to routine health assessments, well child care, and immunizations. Office Visits Specialist Emergency Room Services Coverage is provided for worldwide Emergency Health Services as defined in section 1.39 of the COC. Includes all services provided in an Emergency Room setting. Inpatient Hospital Services benefit applies to emergency room charges if admitted; Outpatient Surgery benefit applies if transferred to an operating room. Emergency Ambulance Services Coverage is provided for Emergencies as defined in Sections 1.39 and 6 of the COC. $500 $1,000 $2,000 $4,000 $3,000,000 $1,000 $2,000 $4,000 $8,000 2 $20 Copay per visit $40 Copay per visit 2 plus 20% $125 Copay per visit Participating Benefit Applies Page 1 of 6

2 Urgent Care Services Urgent Care Services at Alternate Facilities both in and out of the Service Area are Covered. Maternity Care Obstetrician or Certified Nurse Midwife Services Covered Services include routine pre-natal care, delivery (including assistant surgeon), and post-natal care. Regular benefits apply for Complications of Pregnancy. Maternity Care Outpatient Services and Diagnostic Procedures and Tests Covered Services include, but are not limited to lab tests, obstetrical ultrasounds, fetal stress and non-stress testing, and observation. Maternity Care Inpatient Hospital Covered Services include Physician services for mother and newborn(s), newborn nursery services, and Semi-private room. Alcohol and Substance Abuse Services Detoxification Inpatient and outpatient services. Alcohol and Substance Abuse Services Inpatient Rehabilitation Services also include partial hospitalization. Alcohol and Substance Abuse Services Outpatient Counseling Services include office visits and intensive outpatient treatment programs. Mental Health Conditions Inpatient Hospital Mental Health Conditions Partial Hospitalization Coverage is provided for partial or full day nonresidential treatment programs. 2 $75 Copay per visit You pay the same Copay, Coinsurance, and/or as you would pay for medical benefits $40 Copay per visit plus 20% plus 20% plus 20% plus 20% plus 20% Page 2 of 6

3 Mental Health Conditions Intensive Outpatient and Office Visits Outpatient Services and Diagnostic Procedures and Tests Coverage includes diagnostic procedures and tests, including but not limited to lab and radiology, not performed in the Physician s office. Certain procedures and tests are considered surgery, including but not limited to colonoscopy and endoscopy. Refer to the Outpatient Surgery section. Outpatient Surgery Benefits are provided for Covered Services rendered at an outpatient Hospital or freestanding surgery center. Temporomandibular Joint (TMJ) Dysfunction Coverage for Phase I non-surgical treatment. Surgery under Phase II will be Covered as per the Outpatient Surgery or Inpatient Hospital Services (whichever is Medically Necessary) Sections. Refer also to Your COC. Limited to a combined lifetime maximum of $4,000 per Member. High Technology Diagnostic Services, Tests, and Procedures Including, but not limited to: MRI, MRA, CT scans, thallium scans, nuclear stress tests, PET scans, echocardiograms, ultrasounds. Injectable and Implantable Medications Including, but not limited to implantable hormone replacement capsules, chemotherapy drugs, and Injectable Medications that are not usually self-administered. Self-Injectable Medications Medications considered by the Plan to be Self- Injectable Medications are Covered under a Pharmacy Rider, if purchased. $40 Copay per visit 3 3 plus 20% plus 20% plus 20% plus 20% plus 20% plus 20% Page 3 of 6

4 Inpatient Hospital Services Physician and surgeon services, Semi-private room, operating rooms and related facilities, intensive and coronary care units, laboratory, x-rays, radiology services and procedures, medications and biologicals, anesthesia, special duty nursing as prescribed, short-term rehabilitation services, nursing care, meals and special diets. Transplant Services Services and supplies for certain transplants are Covered. Limited to a combined lifetime maximum of $1,000,000 per Member for each type of transplant. Skilled Nursing Facility Coverage is provided in lieu of an inpatient Hospital admission when approved by the Plan. Coverage is provided on a Semi-private basis. Limited to a combined benefit of 30 days per Member, per calendar year. Home Health Care Coverage is provided when services are rendered by licensed Providers and Authorized in advance by the Plan. Limited to a combined benefit of 60 visits per Member, per calendar year. Hospice Coverage is provided when services are rendered by licensed Providers and Authorized in advance by the Plan. Durable Medical Equipment, Prosthetics, Orthotics, and Corrective Appliances Coverage is provided when services are rendered by Providers and Authorized in advance by the Plan. Limited to a combined benefit of $2,500 per Member, per calendar year. 3 plus 20% plus 20% plus 20% plus 20% plus 20% plus 20% Page 4 of 6

5 Medical Supplies disposable medical supplies and accessories. Special Food Products and Enteral Formula Coverage is provided when prescribed for treatment of PKU and other Inherited Metabolic Diseases and when Authorized in advance by the Plan. Special Food Products are limited to a combined benefit of $2,500 per member, per calendar year. This limit does not apply to Enteral Formula. Injectable, Implantable, and Intrauterine Contraceptives/Devices Regular benefits apply for insertion and removal of intrauterine contraceptives/devices and implantable contraceptive capsules. Cardiac and Pulmonary Rehabilitation Outpatient cardiac and pulmonary rehabilitation when Authorized in advance by the Plan. Cardiac rehabilitation: limited to a combined benefit of 30 visits per Member, per calendar year. Pulmonary rehabilitation: limited to a combined benefit of 20 visits per Member, per calendar year. Physical, Occupational, and Speech Therapy Inpatient inpatient physical, occupational, and speech therapy when Authorized in advance by the Plan. 3 plus 20% plus 20% plus 20% Page 5 of 6

6 Physical, Occupational, and Speech Therapy Outpatient outpatient physical, occupational, and speech therapy when Authorized in advance by the Plan. Limited to a combined benefit of 20 visits of each type of therapy per Member, per calendar year. Spinal Manipulation and Chiropractic Care Limited to a combined benefit of 20 visits of each type of therapy per Member, per calendar year. plus 20% 1 Copayments, Coinsurance, and/or s for Out-of-Network benefits are based on the Out-of- Network Rate determined by the Plan. You are responsible for amounts in excess of the Out-of- Network Rate in addition to applicable Copayments, Coinsurance, and s. Please refer to Section 2.7 of Your Certificate of Coverage. 2 Additional Copayment, Coinsurance, and/or may apply for other services provided during a visit, as listed elsewhere in this Schedule. 3 You pay this amount in addition to any applicable Copayment, Coinsurance, and/or for an office visit or an Urgent Care visit. Page 6 of 6