Other Services |
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Mental/Behavioral Health Inpatient Services | 20% | -- | Not Covered | Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. |
Durable Medical Equipment | 20% | -- | Not Covered | Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. |
Routine Foot Care | $40 | -- | Not Covered | Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. |
Hospice Services | No Charge | -- | Not Covered | Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. |
Bariatric Surgery | 20% Coinsurance after deductible | -- | Not Covered | Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. |
Mental/Behavioral Health Outpatient Services | $40 | -- | Not Covered | Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. |
Acupuncture | $40 | -- | Not Covered | Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. |
Rehabilitative Speech Therapy | $40 | -- | Not Covered | Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. |
Rehabilitative Occupational and Rehabilitative Physical Therapy | $40 | -- | Not Covered | Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. |
Abortion for Which Public Funding is Prohibited | 20% | -- | Not Covered | Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. |
Allergy Testing | $80 | -- | Not Covered | Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. |
Chemotherapy | 20% | -- | Not Covered | Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. |
Diabetes Education | No Charge | -- | Not Covered | Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. |
Dialysis | 20% | -- | Not Covered | Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. |
Infusion Therapy | 20% | -- | Not Covered | Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. |
Prosthetic Devices | 20% | -- | Not Covered | Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. |
Radiation | 20% | -- | Not Covered | Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. |
Reconstructive Surgery | 20% Coinsurance after deductible | -- | Not Covered | Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. |
Transplant | 20% Coinsurance after deductible | -- | Not Covered | Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. |
Treatment for Temporomandibular Joint Disorders | 20% Coinsurance after deductible | -- | Not Covered | Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions. |
Additional Benefits | Outpatient Facility Fee (e.g., Ambulatory Surgery Center): 20%
| -- | Outpatient Facility Fee (e.g., Ambulatory Surgery Center): Not Covered
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center): Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
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