Other Services |
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Mental/Behavioral Health Inpatient Services | 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. |
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 Services Office Visit: 20% Mental/Behavioral Health Inpatient Professional Fee: 20% Delivery and all Inpatient Services Professional Fee: 20% Substance Use Disorder Inpatient Professional Fee: 20% Emergency Room Professional Fee: $0
| -- | Outpatient Facility Fee (e.g., Ambulatory Surgery Center): Not Covered Outpatient Services Office Visit: Not Covered Mental/Behavioral Health Inpatient Professional Fee: Not Covered Delivery and all Inpatient Services Professional Fee: Not Covered Substance Use Disorder Inpatient Professional Fee: Not Covered Emergency Room Professional Fee: $0
| 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. Outpatient Services Office Visit: 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 Inpatient Professional Fee: 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. Delivery and all Inpatient Services Professional Fee: 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. Substance Use Disorder Inpatient Professional Fee: 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. Emergency Room Professional Fee: 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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