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Physician Care & Outpatient Services
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| In Network | Out of Network 1 | |
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Deductible Maximum of two deductibles per family per year | $100 per person | $200 per person |
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Coinsurance Maximum | $5,000 | Does not Apply |
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Lifetime Maximum | $2,000,000 |
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Physician Visits | 90% of contract rate, after deductible. | 70% of usual, customary & reasonable, after deductible. |
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| Pre-Certification Not Required |
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Diagnostics, X-Ray, Lab | 90% of contract rate, after deductible. | 70% of usual, customary & reasonable, after deductible. |
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| CT Scans, MRIs, PET Scans and non-obstetrical ultrasound tests require pre-certification regardless of who orders the tests. |
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Chiropractor | 90% of contract rate, after deductible. | 70% of usual, customary & reasonable, after deductible. |
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| Pre-Certification Not Required
$1,500 maximum benefit per calendar year |
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Physical Therapy | 90% of contract rate, after deductible, if pre-certified. | 70% of usual, customary & reasonable, after deductible, if pre-certified. |
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| Pre-certification not required. $3,000 maximum benefit per calendar year for physical therapy & accupuncture combined. |
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Durable Medical Equipment (DME) | 90% of contract rate, after deductible. | 70% of usual, customary & reasonable, after deductible. |
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| DME Costing over $1,000 not covered unless Pre-Certified |
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Outpatient Speciality
Medications/Injectables over $500 | 90% of contract rate, after deductible, when obtained through the PBM Speciality Pharmacy | Not covered unless obtained through the PBM Speciality Pharmacy. |
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| Not covered unless Pre-Certified |
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Hospital Inpatient & Outpatient
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| In Network | Out of Network 1 |
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Pre-Certification Requirement:
Inpatient, Outpatient, and Emergency Admissions | Benefits will not be paid unless Pre-Certified. For emergency admissions, benefits will not be paid unless certification is obtained on first working day following admission. | |
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Room & Board, Miscellaneous Hospital Charges, Surgery, Anesthesia | 90% of contract rate, after deductible. | 70% of usual, customary & reasonable, after deductible. |
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Intensive Care | 90% of contract rate, after deductible. | 70% of usual, customary & reasonable, after deductible. |
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Organ/Tissue Transplants |
At designated Tertiary Care Network Facility; 90% of contract rate, after deductible 2 | 50% of usual, customary & reasonable, after deductible. | |
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Emergency Room,
| 90% of contract rate, after deductible, if emergency.
| 70% of usual, customary & reasonable, after deductible, if emergency.
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| NO COVERAGE UNLESS AN EMERGENCY AS DEFINED BY THE PLAN |
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Urgent Care Center | 90% of contract rate after deductible | 70% of usual, customary & reasonable, after deductible |
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Home Health | 90% of contract rate, after deductible. | 70% of usual, customary & reasonable, after deductible. | |
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| Pre-Certification Required
100 Visit Maximum Per Year |
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Hospice
Inpatient or Outpatient | 90% of contract rate, after deductible. | 70% of usual, customary & reasonable, after deductible. |
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| Pre-Certification Required
$15,000 Lifetime Maximum |
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1. Only in-network benefits count toward the $5,000 coinsurance maximum. Whether or not you live within the network service area, charges incurred out-of-network will never be paid at 100%. Out-of-area benefits: if you live more than 30 miles away from the nearest network provider, benefits will be paid at 80% of usual, customary & reasonable charges.
2. Or 50% of contract rate if facility is part of the PPO Network but not a designated Tertiary Care Network Facility. Your coinsurance if you use a provider which is not part of the Tertiary Care Network will not count towards the $5,000 coinsurance maximum.
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Preventive Health Services
The In-Network deductible is waived, if you use Network providers for Preventive care as defined by the Plan. Non- Network preventive care limited to $300 per person per year.
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| In Network | Non-Network 1 |
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Deductibles/Annual Limit | Deductible Waived | Annual $300 Maximum per Person |
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Well Baby Care from birth to second birthday
| 90% of contract rate. | 70% of usual, customary & reasonable after deductible. |
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Routine Exam
One exam per year ages 2-19 and over 65.
One exam every two years ages 20-64.
| 90% of contract rate. | 70% of usual, customary & reasonable after deductible. |
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Immunizations
| 90% of contract rate. | 70% of usual, customary & reasonable after deductible. |
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Routine Annual Gynecological Visits and Mammography
| 90% of contract rate. | 70% of usual, customary & reasonable after deductible.
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Nicotine Replacement Therapy
To assist participants in quitting smoking | 50% up to a lifetime maximum benefit of $150. |
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Mental/Nervous/Psychiatric Conditions2
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| In Network | Non-Network 1 |
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Inpatient | 90% of contract rate, after deductible. | 70% of usual, customary & reasonable, after deductible |
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| Not covered unless pre-certified |
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Outpatient | 90% of contract rate, after deductible. | 50% of usual, customary & reasonable, no deductible. |
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| Not covered unless pre-certified
20 Visit Yearly Maximum3 |
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Family counseling, grief counseling, outpatient counseling, etc. |
90% of contract rate, after deductible.
| 50% of usual, customary & reasonable, no deductible. |
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| Not covered unless pre-certified
20 Visit Yearly Maximum 3 |
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1. Whether or not you live within the network service area, charges incurred out-of-network will never be paid at 100%. Out-of-area benefits: if you live more than 30 miles away from the nearest network provider, benefits will be paid at 50% of usual, customary & reasonable, and will be reduced by 20% if you do not receive pre-certification.
2. Mental/nervous and counseling claims do not count towards the coinsurance maximum. Mental/nervous and counseling claims do not go towards, and are never eligible for, 100% coverage.
3: Annual 20 visit limit applies to mental/nervous and counseling benefits combined.
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