Other Services |
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Mental/Behavioral Health Inpatient Services | 40% 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 | 40% 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. |
Routine Foot Care | $65 Copay with 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. |
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 | 40% 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 | $65 Copay with deductible | -- | Not Covered | Explanation: The medical deductible does not apply to your first three visits combined for primary care, specialty care, urgent care, mental health, and substance use disorder treatment office visits. |
Acupuncture | $65 Copay 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. |
Rehabilitative Speech Therapy | $65 | -- | 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 | $65 | -- | 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 | 40% 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. |
Allergy Testing | $95 Copay 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. |
Chemotherapy | 40% 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. |
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 | 40% 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. |
Infusion Therapy | 40% 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. |
Prosthetic Devices | 40% 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. |
Radiation | 40% 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. |
Reconstructive Surgery | 40% 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 | 40% 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 | 40% 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): 40% after ded. Outpatient Services Office Visit: 40% after ded. Mental/Behavioral Health Inpatient Professional Fee: 40% after ded. Delivery and all Inpatient Services Professional Fee: 40% after ded. Substance Use Disorder Inpatient Professional Fee: 40% after ded. 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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