Early Intervention Services (EIS). For children from birth to 36 months The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% YES 0% The level of coverage is the same as network provider. YES The level of coverage is the same as network provider. Education Asthma Management 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam 0% YES Not Covered Not Covered Diagnostic Testing 0% YES Not Covered Not Covered Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 0% YES The level of coverage is the same as network provider. Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered Coverage varies based on type of hemophilia service. Home Health Care In your home Intermittent skilled services when billed by a home health care agency. 0% YES Not Covered Not Covered Prescription drug Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. 0% YES The level of coverage is the same as network provider. Human Leukocyte Antigen Human Leukocyte Antigen Testing 0% YES Not Covered Not Covered Testing Infertility Inpatient/ outpatient/in a doctor’s office Three (3) infertility treatment cycles will be covered per benefit year with a total of eight (8) infertility treatment 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 0% YES Not Covered Not Covered Inpatient Physician Hospital Visits Inpatient 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 0% YES Not Covered Not Covered Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist 0% YES Not Covered Not Covered Hospital based clinic visits for adults 0% YES Not Covered Not Covered House Calls rendered by personal care physician ▇▇▇▇ ▇▇▇▇▇ First, second, or third submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visits. $25 NO Not Covered Not Covered Subsequent submitted claims for sick office visits in a benefit year. 0% YES House Calls rendered by Specialist 0% YES Not Covered Not Covered Pediatric Clinic visit Sick Visit First, second, or third $25 NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visits. Subsequent submitted claims for sick office visits in a benefit year. 0% YES Personal Care Physician (PCP) See Prevention and Early Detection Services for coverage of annual preventive office visit. Sick Visit First, second, or third submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visits. $25 NO Not Covered Not Covered Subsequent submitted claims for sick office visits in a benefit year. 0% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Podiatrist Services Routine foot care is not covered. 0% YES Not Covered Not Covered Specialist Visits Routine and non-routine visits. 0% YES Not Covered Not Covered Organ Transplants 0% YES Not Covered Not Covered Physical/ Occupational Therapy * Outpatient hospital/In a doctor’s/ therapist’s office Preauthorization is recommended for the eleventh (11th) and subsequent visits. 0% YES Not Covered Not Covered Covered health care services include rehabilitative and habilitative services. Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 0% YES Not Covered Not Covered Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 0% YES Not Covered Not Covered Infused drugs 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: provider (other than a pharmacist) Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details. Prevention and Early Detection Services Adult annual preventive visit One (1) routine adult physical examination per benefit year per member will be covered. 0% NO Not Covered Not Covered Well woman annual preventive visit One (1) routine gynecological examination per benefit year per female member will be covered. 0% NO Not Covered Not Covered Pediatric preventive office visit Well-Child Office Visits: Birth - 15 months: 8 visits; 16 - 35 months: 3 visits; 36 months - 19 years: 1 per benefit year. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Pediatric preventive clinic 0% NO Not Covered Not Covered Diabetes education Individual and group sessions are covered. 0% NO Not Covered Not Covered Nutritional counseling Unlimited visits per benefit year when prescribed by a physician. 0% NO Not Covered Not Covered Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO Not Covered Not Covered Adult Immunization 0% NO Not Covered Not Covered Pediatric Immunization 0% NO Not Covered Not Covered Travel Immunization 0% NO Not Covered Not Covered Allergy injections Applies to injection only including administration. 0% YES Not Covered Not Covered Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. Prevention and Early Detection Services Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO Not Covered Not Covered Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO Not Covered Not Covered Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO Not Covered Not Covered Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Manual breast pumps In conjunction with birth. 0% NO Not Covered Not Covered Private Duty Nursing 0% YES Not Covered Not Covered Radiation Therapy/ Chemotherapy Services Outpatient 0% YES Not Covered Not Covered In a doctor’s office 0% YES Not Covered Not Covered Respiratory Therapy 0% YES Not Covered Not Covered Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES Not Covered Not Covered Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 0% YES Not Covered Not Covered Surgery Services Inpatient 0% YES Not Covered Not Covered Outpatient 0% YES Not Covered Not Covered In a doctor’s office 0% YES Not Covered Not Covered Tests, Imaging*, and Labs (includes machine tests and x-rays) Outpatient Hospital Facility/ Outpatient Non- Hospital facility including in a Doctor’s office, urgent care Applies to the following diagnostic imaging services: • MRI; • MRA; • CAT scans; • CTA scans; 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? center, or free- standing laboratory • PET scans; and • Nuclear Cardiac Imaging. Preauthorization is recommended for these diagnostic imaging services. For tests, imaging and lab, other than the diagnostic imaging services listed above. 0% YES Not Covered Not Covered Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services - Preventive Screening for preventive colorectal services. 0% YES Not Covered Not Covered Lyme Disease- Diagnosis/ Treatment 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Urgent care facility Urgent care facility/walk-in See Section 8.0 - definition of urgent care center. 0% YES The level of coverage is the same as network provider. Vision care services Eye Exam In a doctor’s office One routine eye exam per benefit year, including one pediatric vision exam for a member up to age 19. Medically necessary eye exams are covered. 0% YES Not Covered Not Covered Vision Hardware for a member aged 19 and older Not Covered Not Covered Not Covered Not Covered Vision Hardware for a member under the age of 19 Prescription glasses - Frames One pair of collection prescription frames per benefit year. Non-collection prescription frames are NOT covered. 0% NO Not Covered Not Covered One pair of glass or plastic lenses per benefit year. This includes single vision, bifocal, trifocal, 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? lenticular, and standard progressive lens. The following lens treatments are covered: • UV treatment; • Tint (fashion, gradient, and glass- grey) • Standard plastic scratch coating; • Standard polycarbonate; • Photocromatic/ transitions plastic Contact Lens One supply of collection contact lenses (Extended Wear OR Daily Wear OR Conventional) covered in lieu of Prescription glasses. Includes evaluation, fitting or follow-up care relating to contact lenses. Non-collection contact lenses are NOT covered. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? The following contact lenses are covered: • Extended Wear Disposables are covered up to the benefit limit of a six (6) month supply of monthly or two (2) week disposables in a benefit year. • Daily Wear Disposable are covered up to the benefit limit of a three (3) month supply of daily disposable lenses in a benefit year. • Conventional contact lens limited to one per benefit year. 0% NO Not Covered Not Covered One additional supply (as indicated above) of contact lenses may be covered for certain conditions: • Anisometropia • High Ametropia • Keratoconus • Vision improvement for members whose 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? vision can be corrected two lines of improvement. Preauthorization recommended. Prescription drugs for which preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. • Prescription drugs - ask your prescribing physician to call the number listed for the “Pharmacist” on the back of your ID card. To see if prescription drug requires preauthorization, call our Customer Service Department or visit our Web site.

Appears in 1 contract

Sources: Subscriber Agreement

Early Intervention Services (EIS). For children from birth to 36 months The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% ~~YES~~ NO 0% The level of coverage is the same as network provider. ~~YES~~ NO The level of coverage is the same as network provider. ~~Education Asthma Management 0% YES Not Covered Not Covered~~ Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Education Asthma Management $0 NO 30% YES Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam 0$50 NO 30% YES ~~Not Covered Not Covered~~ Diagnostic Testing 010% YES ~~Not Covered Not Covered~~ 30% YES Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 010% YES The level of coverage is the same as network provider. Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. ~~0% YES Not Covered Not Covered~~ Coverage varies based on type of hemophilia service. 10% YES 30% YES Home Health Care In your home Intermittent skilled services when billed by a home health care agency. 0% YES Not Covered Not Covered Prescription drug Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 010% YES Not Covered Not Covered Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. 0% YES The level of coverage is the same as network provider. Human Leukocyte Antigen Human Leukocyte Antigen Testing 0% YES Not Covered Not Covered Testing Infertility Inpatient/ outpatient/in a doctor’s office Three (3) infertility treatment cycles will be covered per benefit year with a total of eight (8) infertility treatment 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 0% YES Not Covered Not Covered Inpatient Physician Hospital Visits Inpatient 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 0% YES Not Covered Not Covered Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist 0% YES Not Covered Not Covered Hospital based clinic visits for adults 0% YES Not Covered Not Covered House Calls rendered by personal care physician ▇▇▇▇ ▇▇▇▇▇ First, second, or third submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visits. $25 NO Not Covered Not Covered Subsequent submitted claims for sick office visits in a benefit year. 0% YES House Calls rendered by Specialist 0% YES Not Covered Not Covered Pediatric Clinic visit Sick Visit First, second, or third $25 NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visits. Subsequent submitted claims for sick office visits in a benefit year. 0% YES Personal Care Physician (PCP) See Prevention and Early Detection Services for coverage of annual preventive office visit. Sick Visit First, second, or third submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visits. $25 NO Not Covered Not Covered Subsequent submitted claims for sick office visits in a benefit year. 030% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: ~~Your copayment Does the deductible apply? Your copayment Does the deductible apply? Podiatrist Services Routine foot~~ Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is ~~not covered~~based on type of service and site of service. 0See Summary of Pharmacy Benefits for details. 10% YES ~~Not Covered Not Covered Specialist Visits Routine and non-routine visits. 0~~30% YES ~~Not Covered Not Covered Organ Transplants 0~~Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. $200 NO The level of coverage is the same as network provider. Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 10% YES ~~Not Covered Not Covered Physical/ Occupational Therapy * Outpatient hospital~~30% YES Infertility Inpatient/ outpatient/In in a ~~doctor’s/ therapist~~doctor’s office ~~Preauthorization~~ Three (3) infertility treatment cycles will be covered per benefit year with a total of eight (8) infertility treatment cycles covered in a member’s lifetime. Prescription drug coverage benefit level is ~~recommended~~ based on type of service and site of service. See Summary of Pharmacy Benefits for ~~the eleventh (11th) and subsequent visits~~details. 010% YES ~~Not Covered Not Covered Covered health care services include rehabilitative and habilitative services. Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 0~~30% YES Not Covered Not Covered Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 0% YES Not Covered Not Covered Infused drugs 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: ~~provider (other than a pharmacist)~~ Infusion Therapy Outpatient Prescription ~~Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy~~ drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. ~~Prevention~~ 10% YES 30% YES In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and ~~Early Detection~~ site of service. See Summary of Pharmacy Benefits for details. 10% YES 30% YES Inpatient Hospital Services ~~Adult annual preventive visit One (1) routine adult physical examination per benefit year per member will be covered~~Inpatient* Unlimited days at general hospital or a specialty hospital. 010% ~~NO Not Covered Not Covered Well woman annual preventive visit One (1) routine gynecological examination per benefit year per female member will be covered. 0~~YES 30% ~~NO Not Covered Not Covered Pediatric preventive office visit Well-Child Office Visits: Birth - 15 months: 8 visits; 16 - 35 months: 3 visits; 36 months - 19 years: 1~~ YES Inpatient Physician Hospital Visits Inpatient 10% YES 30% YES Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 010% YES 30% YES Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist $50 NO ~~Not Covered Not Covered~~ 30% YES Hospital based clinic visits for adults $50 NO 30% YES House Calls rendered by primary care physician PCP practices with PCMH model of care. $15 NO 30% YES PCP does NOT practice with PCMH model of care. $35 NO Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: ~~Your copayment Does~~ Office Visits (other than office visits for Behavioral Health and annual preventive care) (continued) House Calls rendered by Specialist $50 NO 30% YES Pediatric Clinic visit PCP practices with PCMH model of care. $15 NO 30% YES PCP does NOT practice with PCMH model of care. $35 NO Primary Care Physician (PCP) First non-preventive office visit in the ~~deductible apply? Your copayment Does~~ calendar year rendered by a PCP or Behavioral Health PCP. Benefit applies per member, per calendar year. $0 NO 30% YES Subsequent non- preventive office visits in the ~~deductible apply? Pediatric~~ calendar year - PCP practices with PCMH model of care. $15 NO Subsequent non- preventive ~~clinic 0%~~ office visits in the calendar year - PCP does not practice with PCMH model of care. $35 NO ~~Not Covered Not Covered Diabetes education Individual and group sessions are~~ Podiatrist Services Routine foot care is not covered. 0% $50 NO Not Covered Not Covered Nutritional counseling Unlimited visits per benefit year when prescribed by a physician. 0% NO Not Covered Not Covered Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO Not Covered Not Covered Adult Immunization 0% NO Not Covered Not Covered Pediatric Immunization 0% NO Not Covered Not Covered Travel Immunization 0% NO Not Covered Not Covered Allergy injections Applies to injection only including administration. 030% YES ~~Not Covered Not Covered Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, 0~~Retail Clinics See Section 3.23 – Office Visits for details. $50 NO 30% YES Specialist Visits Routine and non- routine visits. $50 NO ~~Not Covered Not Covered~~ 30% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: ~~Your copayment Does the deductible apply? Your copayment Does the deductible apply? flexible sigmoidoscopy~~Organ Transplants 10% YES 30% YES Physical/ Occupational Therapy Outpatient hospital/In a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 10% YES 30% YES Pregnancy Services and Nursery Care Pre-natal, ~~colonoscopy, double contrast barium enema~~delivery, and ~~fecal occult blood tests~~postpartum services. 10% YES 30% YES Prescription drugs, screening for gestational diabetes, and human papillomavirus. Prevention and Early Detection Services Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO Not Covered Not Covered Contraceptive and Sterilization Services for women other than Specialty Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist)) Medications other than injected and infused drugs. ~~For prescription~~ Are included in the allowance for the medical service being rendered. Injectable drugs ~~purchased~~ 10% YES 30% YES Infused drugs 10% YES 30% YES Prescription Drugs Purchased at a ~~pharmacy~~Retail, ~~see the~~ Specialty, or Mail Order Pharmacy See Summary of Pharmacy ~~Benefits~~Benefits for details. 0% NO Not Covered Not Covered Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO Not Covered Not Covered Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Manual breast pumps In conjunction with birth. 0% NO Not Covered Not Covered Private Duty Nursing 0% YES Not Covered Not Covered Radiation Therapy/ Chemotherapy Services Outpatient 0% YES Not Covered Not Covered In a doctor’s office 0% YES Not Covered Not Covered Respiratory Therapy 0% YES Not Covered Not Covered Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES Not Covered Not Covered Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 0% YES Not Covered Not Covered Surgery Services Inpatient 0% YES Not Covered Not Covered Outpatient 0% YES Not Covered Not Covered In a doctor’s office 0% YES Not Covered Not Covered Tests, Imaging*, and Labs (includes machine tests and x-rays) Outpatient Hospital Facility/ Outpatient Non- Hospital facility including in a Doctor’s office, urgent care Applies to the following diagnostic imaging services: • MRI; • MRA; • CAT scans; • CTA scans; 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? center, or free- standing laboratory • PET scans; and • Nuclear Cardiac Imaging. Preauthorization is recommended for these diagnostic imaging services. For tests, imaging and lab, other than the diagnostic imaging services listed above. 0% YES Not Covered Not Covered Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services - Preventive Screening for preventive colorectal services. 0% YES Not Covered Not Covered Lyme Disease- Diagnosis/ Treatment 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Urgent care facility Urgent care facility/walk-in See Section 8.0 - definition of urgent care center. 0% YES The level of coverage is the same as network provider. Vision care services Eye Exam In a doctor’s office One routine eye exam per benefit year, including one pediatric vision exam for a member up to age 19. Medically necessary eye exams are covered. 0% YES Not Covered Not Covered Vision Hardware for a member aged 19 and older Not Covered Not Covered Not Covered Not Covered Vision Hardware for a member under the age of 19 Prescription glasses - Frames One pair of collection prescription frames per benefit year. Non-collection prescription frames are NOT covered. 0% NO Not Covered Not Covered One pair of glass or plastic lenses per benefit year. This includes single vision, bifocal, trifocal, 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? lenticular, and standard progressive lens. The following lens treatments are covered: • UV treatment; • Tint (fashion, gradient, and glass- grey) • Standard plastic scratch coating; • Standard polycarbonate; • Photocromatic/ transitions plastic Contact Lens One supply of collection contact lenses (Extended Wear OR Daily Wear OR Conventional) covered in lieu of Prescription glasses. Includes evaluation, fitting or follow-up care relating to contact lenses. Non-collection contact lenses are NOT covered. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? The following contact lenses are covered: • Extended Wear Disposables are covered up to the benefit limit of a six (6) month supply of monthly or two (2) week disposables in a benefit year. • Daily Wear Disposable are covered up to the benefit limit of a three (3) month supply of daily disposable lenses in a benefit year. • Conventional contact lens limited to one per benefit year. 0% NO Not Covered Not Covered One additional supply (as indicated above) of contact lenses may be covered for certain conditions: • Anisometropia • High Ametropia • Keratoconus • Vision improvement for members whose 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? vision can be corrected two lines of improvement. Preauthorization recommended. Prescription drugs for which preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. • Prescription drugs - ask your prescribing physician to call the number listed for the “Pharmacist” on the back of your ID card. To see if prescription drug requires preauthorization, call our Customer Service Department or visit our Web site.:

Appears in 1 contract

Sources: Subscriber Agreement

Early Intervention Services (EIS). For children from birth to 36 months The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% YES ~~0% The level of coverage is the same as network provider. YES~~ The level of coverage is the same as network provider. Education Asthma Management 0% YES Not Covered Not Covered Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Hearing Exam 0% YES Not Covered Not Covered Diagnostic Testing 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: ~~Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam 0% YES Not Covered Not Covered Diagnostic Testing 0% YES Not Covered Not Covered~~ Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 0% YES The level of coverage is the same as network provider. Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered Coverage varies based on type of hemophilia service. Home Health Care In your home Intermittent skilled services when billed by a home health care agency. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered ~~Prescription drug~~ Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. 0% YES The level of coverage is the same as network provider. Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 0% YES Not Covered Not Covered ~~Testing~~ Infertility Inpatient/ outpatient/in a doctor’s office Three (3) infertility treatment cycles will be covered per benefit year with a total of eight (8) infertility treatment cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 0% YES Not Covered Not Covered Inpatient Physician Hospital Visits Inpatient 0% YES Not Covered Not Covered Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 0% YES Not Covered Not Covered Office Visits (other than office visits for Behavioral Health and annual preventive care) Office Visits Allergist & Dermatologist 0% YES Not Covered Not Covered Hospital based clinic visits for adults 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: ~~Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 0% YES Not Covered Not Covered Office Visits~~ (other than office visits for Behavioral Health and annual preventive care) ~~Allergist & Dermatologist 0% YES Not Covered Not Covered Hospital based clinic visits for adults 0% YES Not Covered Not Covered~~ House Calls rendered by ~~personal care physician ▇▇▇▇ ▇▇▇▇▇~~ Primary Care Physician Sick Visit First, second, or third submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visits. $25 NO Not Covered Not Covered Subsequent submitted claims for sick office visits in a benefit year. 0% YES Not Covered Not Covered House Calls rendered by Specialist 0% YES Not Covered Not Covered Pediatric Clinic visit Sick Visit First, second, or third submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visits. $25 NO Not Covered Not Covered Office Visits (other than Subsequent submitted claims for sick office visits in a benefit year. 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: ~~Your copayment Does the deductible apply? Your copayment Does the deductible apply? submitted claim for a sick office visit in a benefit year. Benefit limit applies to all~~ office visits ~~rendered by a PCP, except the~~ for Behavioral Health and annual preventive ~~care office visits. Subsequent submitted claims for sick office visits in a benefit year. 0% YES Personal~~ care) Primary Care Physician (PCP) See Prevention and Early Detection Services for coverage of annual preventive office visit. Sick Visit First, second, or third submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visits. $25 NO Not Covered Not Covered Subsequent submitted claims for sick office visits in a benefit year. 0% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Not Covered Not Covered Podiatrist Services Routine foot care is not covered. 0% YES Not Covered Not Covered Specialist Visits Routine and ~~non-~~non- routine visits. 0% YES Not Covered Not Covered Organ Transplants 0% YES Not Covered Not Covered Physical/ Occupational Therapy * Outpatient hospital/In a doctor’s/ therapist’s office Preauthorization is recommended for the eleventh (11th) and subsequent visits. ~~0% YES Not Covered Not Covered~~ Covered health care services include rehabilitative and habilitative services. Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 0% YES Not Covered Not Covered Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 0% YES Not Covered Not Covered Infused drugs 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 0% YES Not Covered Not Covered Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 0% YES Not Covered Not Covered Infused drugs 0% YES Not Covered Not Covered Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details. Prevention and Early Detection Services Prevention and Adult annual preventive visit One (1) routine adult physical examination per benefit year per member will be covered. 0% NO Not Covered Not Covered Well woman annual preventive visit One (1) routine gynecological examination per benefit year per female member will be covered. 0% NO Not Covered Not Covered Pediatric preventive office visit Well-Child Office Visits: Birth - 15 months: 8 visits; 16 - 35 months: 3 visits; 36 months - 19 years: 1 per benefit year. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: ~~Your copayment Does the deductible apply? Your copayment Does the deductible apply?~~ Early Detection Services Prevention and Early Detection Well woman annual preventive visit One (1) routine gynecological examination per benefit year per female member will be covered. 0% NO Not Covered Not Covered Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 1 per benefit year. 0% NO Not Covered Not Covered Pediatric preventive clinic 0% NO Not Covered Not Covered Diabetes education Individual and group sessions are covered. 0% NO Not Covered Not Covered Nutritional counseling Unlimited visits per benefit year when prescribed by a physician. 0% NO Not Covered Not Covered Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO Not Covered Not Covered Adult Immunization 0% NO Not Covered Not Covered Pediatric Immunization 0% NO Not Covered Not Covered Travel Immunization 0% NO Not Covered Not Covered Allergy injections Applies to injection only including administration. 0% YES Not Covered Not Covered Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: ~~Your copayment Does~~ Services Prevention and Early Detection Services Allergy injections Applies to injection only including administration. 0% YES Not Covered Not Covered Preventive screenings Coverage includes, but is not limited to, the ~~deductible apply? Your copayment Does the deductible apply?~~ following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. ~~Prevention and Early Detection Services~~ 0% NO Not Covered Not Covered Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO Not Covered Not Covered Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO Not Covered Not Covered Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO Not Covered Not Covered Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Contraceptive and Sterilization Services for women Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO Not Covered Not Covered Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO Not Covered Not Covered Manual breast pumps In conjunction with birth. 0% NO Not Covered Not Covered Private Duty Nursing 0% YES Not Covered Not Covered Radiation Therapy/ Chemotherapy Services Outpatient 0% YES Not Covered Not Covered In a doctor’s office 0% YES Not Covered Not Covered Respiratory Therapy 0% YES Not Covered Not Covered Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES Not Covered Not Covered Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 0% YES Not Covered Not Covered Surgery Services Surgery Services Inpatient 0% YES Not Covered Not Covered Outpatient 0% YES Not Covered Not Covered In a doctor’s office 0% YES Not Covered Not Covered Tests, Imaging*, and Labs (includes machine tests and x-rays) Outpatient Hospital Facility/ Outpatient Non- Hospital facility including in a Doctor’s office, urgent care Applies to the following diagnostic imaging services: • MRI; • MRA; • CAT scans; • CTA scans; 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: ~~Your copayment Does the deductible apply? Your copayment Does the deductible apply?~~ Tests, Imaging*, and Labs (includes machine tests and x-rays) Outpatient Hospital Facility/ Outpatient Non- Hospital facility including in a Doctor’s office, urgent care center, or free- standing laboratory Applies to the following diagnostic imaging services: • MRI; • MRA; • CAT scans; • CTA scans; • PET scans; and • Nuclear Cardiac Imaging. Preauthorization is recommended for these diagnostic imaging services. 0% YES Not Covered Not Covered For tests, imaging and lab, other than the diagnostic imaging services listed above. 0% YES Not Covered Not Covered Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services - Preventive Screening for preventive colorectal services. 0% YES Not Covered Not Covered ~~Lyme Disease- Diagnosis/ Treatment 0% YES Not Covered Not Covered~~ Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Tests, Imaging*, and Labs (includes machine tests and x-rays) Lyme Disease- Diagnosis/ Treatment 0% YES Not Covered Not Covered Urgent care facility Urgent care facility/walk-in See Section 8.0 - definition of urgent care center. 0% YES The level of coverage is the same as network provider. Vision care services Eye Exam In a doctor’s office One routine eye exam per benefit year, without diagnosis of diabetes, including one pediatric vision exam for a member up to age 19. Medically necessary eye exams are covered. 0% YES Not Covered Not Covered Vision Hardware for a member aged 19 and older Not Covered Not Covered Not Covered Not Covered Vision Hardware for a member under the age of 19 Prescription glasses - Frames One pair of collection prescription frames per benefit year. Non-collection prescription frames are NOT covered. 0% NO Not Covered Not Covered ~~One pair of glass or plastic lenses per benefit year. This includes single vision, bifocal, trifocal, 0% NO Not Covered Not Covered~~ Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: ~~Your copayment Does~~ Vision Hardware for a member under the ~~deductible apply? Your copayment Does the deductible apply?~~ age of 19 One pair of glass or plastic lenses per benefit year. This includes single vision, bifocal, trifocal, lenticular, and standard progressive lens. The following lens treatments are covered: • UV treatment; • Tint (fashion, gradient, and glass- grey) • Standard plastic scratch coating; • Standard polycarbonate; • Photocromatic/ transitions plastic 0% NO Not Covered Not Covered Contact Lens One supply of collection contact lenses (Extended Wear OR Daily Wear OR Conventional) covered in lieu of Prescription glasses. Includes evaluation, fitting or follow-up care relating to contact lenses. Non-collection contact lenses are NOT covered. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: ~~Your copayment Does~~ Vision Hardware for a member under the ~~deductible apply? Your copayment Does the deductible apply?~~ age of 19 The following contact lenses are covered: • Extended Wear Disposables are covered up to the benefit limit of a six (6) month supply of monthly or two (2) week disposables in a benefit year. • Daily Wear Disposable are covered up to the benefit limit of a three (3) month supply of daily disposable lenses in a benefit year. • Conventional contact lens limited to one per benefit year. 0% NO Not Covered Not Covered One additional supply (as indicated above) of contact lenses may be covered for certain conditions: • Anisometropia • High Ametropia • Keratoconus • Vision improvement for members whose vision can be corrected two lines of improvement. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: ~~Your copayment Does~~ Vision Hardware for a member under the ~~deductible apply? Your copayment Does the deductible apply? vision can be corrected two lines~~ age of ~~improvement.~~ 19 Preauthorization recommended. Prescription drugs for which preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. • Preauthorization is required for certain brand name prescription drugs and certain specialty Prescription Drugs. For details on how to obtain prescription drug preauthorization for a prescription drug, see Section 1.6 and Section 3.27 - subsection “How to Obtain Prescription Drug Preauthorization. Prescription drugs ~~- ask your prescribing physician to call~~ in our formulary are placed into the ~~number listed~~ following tiers, or levels, for copayment purposes: Tier 1 – generally low cost preferred generic drugs, which require the ~~“Pharmacist” on the back of your ID card~~lowest copayment. ~~To see if prescription drug requires preauthorization~~Tier 2 – generally includes other certain formulary low cost preferred generic Prescription Drugs, ~~call our Customer Service Department or visit our Web site.~~which require a higher

Appears in 1 contract

Sources: Subscriber Agreement

Early Intervention Services (EIS). For children from birth to 36 months The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% ~~YES 0%~~ NO The level of coverage is the same as network provider. ~~YES~~ The level of coverage is the same as network provider. Education Asthma Management 0$0 NO 40% YES ~~Not Covered Not Covered~~ Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam $40 NO 40% YES Diagnostic Testing 20% YES 40% YES Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 20% YES The level of coverage is the same as network provider. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam 0% YES Not Covered Not Covered Diagnostic Testing 0% YES Not Covered Not Covered Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 0% YES The level of coverage is the same as network provider. Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. ~~0% YES Not Covered Not Covered~~ Coverage varies based on type of hemophilia service. 20% YES 40% YES Home Health Care In your home Intermittent skilled services when billed by a home health care agency. 0Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 20% YES ~~Not Covered Not Covered~~ 40% YES Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 20% YES 40% YES Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. $200 NO The level of coverage is the same as network provider. Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 20% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. 0% YES The level of coverage is the same as network provider. Human Leukocyte Antigen Human Leukocyte Antigen Testing 0% YES Not Covered Not Covered Testing Infertility Inpatient/ outpatient/in a doctor’s office Three (3) infertility treatment cycles will be covered per benefit year with a total of eight (8) infertility treatment 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 20% YES 20% YES Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 020% YES ~~Not Covered Not Covered~~ 40% YES In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 020% YES ~~Not Covered Not Covered~~ 40% YES Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 020% YES ~~Not Covered Not Covered Inpatient Physician Hospital Visits Inpatient 0~~40% YES ~~Not Covered Not Covered~~ Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Inpatient Physician Hospital Visits Inpatient 20% YES 40% YES Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 020% YES ~~Not Covered Not Covered~~ 40% YES Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist 0$40 NO 40% YES ~~Not Covered Not Covered~~ Hospital based clinic visits for adults 0% YES Not Covered Not Covered House Calls rendered by personal care physician ▇▇▇▇ ▇▇▇▇▇ First, second, or third submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visits. $25 40 NO ~~Not Covered Not Covered Subsequent submitted claims for sick office visits in a benefit year. 0~~40% YES House Calls rendered by ~~Specialist 0~~primary care physician PCP practices with PCMH model of care. $15 NO 40% YES ~~Not Covered Not Covered~~ PCP does NOT practice with PCMH model of care. $25 NO House Calls rendered by Specialist $40 NO 40% YES Pediatric Clinic visit ~~Sick Visit First, second, or third~~ PCP practices with PCMH model of care. $15 NO 40% YES PCP does NOT practice with PCMH model of care. $25 NO ~~Not Covered Not Covered~~ Primary Care Physician (PCP) First non-preventive office visit in the calendar year rendered by a PCP or Behavioral Health PCP. Benefit applies per member, per calendar year. $0 NO 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: ~~Your copayment Does the deductible apply? Your copayment Does the deductible apply? submitted claim for a sick office visit in a benefit year. Benefit limit applies to all~~ Office Visits (other than office visits ~~rendered by a PCP, except the~~ for Behavioral Health and annual preventive ~~care office visits. Subsequent submitted claims for sick office visits in a benefit year. 0% YES Personal~~ care) (continued) Primary Care Physician (PCP) (continued) Subsequent non- preventive office visits in the calendar year - PCP practices with PCMH model of care. $15 NO Subsequent non- preventive office visits in the calendar year - PCP does not practice with PCMH model of care. $25 NO Podiatrist Services Routine foot care is not covered. $40 NO 40% YES Retail Clinics See Section 3.23 – Office Visits for details. $40 NO 40% YES Specialist Visits Routine and non- routine visits. $40 NO 40% YES Organ Transplants 20% YES 40% YES Physical/ Occupational Therapy Outpatient hospital/In a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 20% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 20% YES 40% YES Infused drugs 20% YES 40% YES Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details. Prevention and Early Detection Services ~~for coverage of~~ Adult annual preventive visit One (1) routine adult physical examination per benefit year per member will be covered. 0% NO 40% YES Well woman annual preventive visit One (1) routine gynecological examination per benefit year per female member will be covered. 0% NO 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Prevention and Early Detection Services (continued) Pediatric preventive office visit Well-Child Office Visits: Birth - 35 months: 11 visits; 36 months - 19 years: 0% NO 40% YES 1 per benefit year. Pediatric preventive 0% NO 40% YES clinic Diabetes Individual and group 0% NO 40% YES education sessions are covered. Nutritional Unlimited visits per counseling benefit year when prescribed by a 0% NO 40% YES physician. Smoking For nicotine cessation replacement therapy counseling (NRT) and smoking cessation prescription drugs, see the 0% NO 40% YES Summary of Pharmacy Benefits. Adult 0% NO 40% YES Immunization Pediatric 0% NO 40% YES Immunization Travel 0% NO 40% YES Immunization Allergy Applies to injection injections only including administration. 20% YES 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Prevention and Early Detection Services (continued) Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. 0% NO 40% YES Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 40% YES Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO 40% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. Sick Visit First, second, or third submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visits. $25 0% NO ~~Not Covered Not Covered Subsequent submitted claims for sick office visits in a benefit year. 0~~40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? ~~Podiatrist~~ Contraceptive and Sterilization Services ~~Routine foot care is~~ for women (continued) Surgical services, including, but not ~~covered~~limited to, tubal ligation and insertion/removal of IUD. 0% NO 40% YES ~~Not Covered Not Covered Specialist Visits Routine and non-routine visits~~Manual breast pumps In conjunction with birth. 0% ~~YES Not Covered Not Covered Organ Transplants 0~~NO 40% YES ~~Not Covered Not Covered Physical/ Occupational~~ Private Duty Nursing* Must be performed by a certified home health care agency. 20% YES 40% YES Radiation Therapy/ Chemotherapy Services Outpatient 20% YES 40% YES In a doctor’s office 20% YES 40% YES Respiratory Therapy 20% YES 40% YES Skilled Nursing Facility Care* ~~Outpatient hospital~~Skilled or Sub- acute 20% YES 40% YES Speech Therapy* Outpatient/In in a doctor’s/ therapist’s office ~~Preauthorization is recommended for the eleventh (11th) and subsequent visits. 0% YES Not Covered Not Covered~~ Covered health care services include rehabilitative and habilitative services. ~~Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 0~~20% YES Not Covered Not Covered Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 040% YES ~~Not Covered Not Covered Infused drugs 0~~Surgery Services Inpatient 20% YES ~~Not Covered Not Covered~~ 40% YES Outpatient 20% YES 40% YES In a doctor’s office $20 NO 40% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: provider (other than a pharmacist) Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details. Prevention and Early Detection Services Adult annual preventive visit One (1) routine adult physical examination per benefit year per member will be covered. 0% NO Not Covered Not Covered Well woman annual preventive visit One (1) routine gynecological examination per benefit year per female member will be covered. 0% NO Not Covered Not Covered Pediatric preventive office visit Well-Child Office Visits: Birth - 15 months: 8 visits; 16 - 35 months: 3 visits; 36 months - 19 years: 1 per benefit year. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Pediatric preventive clinic 0% NO Not Covered Not Covered Diabetes education Individual and group sessions are covered. 0% NO Not Covered Not Covered Nutritional counseling Unlimited visits per benefit year when prescribed by a physician. 0% NO Not Covered Not Covered Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO Not Covered Not Covered Adult Immunization 0% NO Not Covered Not Covered Pediatric Immunization 0% NO Not Covered Not Covered Travel Immunization 0% NO Not Covered Not Covered Allergy injections Applies to injection only including administration. 0% YES Not Covered Not Covered Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. Prevention and Early Detection Services Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO Not Covered Not Covered Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO Not Covered Not Covered Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO Not Covered Not Covered Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Manual breast pumps In conjunction with birth. 0% NO Not Covered Not Covered Private Duty Nursing 0% YES Not Covered Not Covered Radiation Therapy/ Chemotherapy Services Outpatient 0% YES Not Covered Not Covered In a doctor’s office 0% YES Not Covered Not Covered Respiratory Therapy 0% YES Not Covered Not Covered Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES Not Covered Not Covered Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 0% YES Not Covered Not Covered Surgery Services Inpatient 0% YES Not Covered Not Covered Outpatient 0% YES Not Covered Not Covered In a doctor’s office 0% YES Not Covered Not Covered Tests, Imaging*, and Labs (includes machine tests and x-rays) Outpatient Hospital Facility/ Outpatient Non- Hospital facility including in a Doctor’s office, urgent care Applies to the following diagnostic imaging services: • MRI; • MRA; • CAT scans; • CTA scans; 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? center, or free- standing laboratory • PET scans; and • Nuclear Cardiac Imaging. Preauthorization is recommended for these diagnostic imaging services. For tests, imaging and lab, other than the diagnostic imaging services listed above. 0% YES Not Covered Not Covered Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services - Preventive Screening for preventive colorectal services. 0% YES Not Covered Not Covered Lyme Disease- Diagnosis/ Treatment 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Urgent care facility Urgent care facility/walk-in See Section 8.0 - definition of urgent care center. 0% YES The level of coverage is the same as network provider. Vision care services Eye Exam In a doctor’s office One routine eye exam per benefit year, including one pediatric vision exam for a member up to age 19. Medically necessary eye exams are covered. 0% YES Not Covered Not Covered Vision Hardware for a member aged 19 and older Not Covered Not Covered Not Covered Not Covered Vision Hardware for a member under the age of 19 Prescription glasses - Frames One pair of collection prescription frames per benefit year. Non-collection prescription frames are NOT covered. 0% NO Not Covered Not Covered One pair of glass or plastic lenses per benefit year. This includes single vision, bifocal, trifocal, 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? lenticular, and standard progressive lens. The following lens treatments are covered: • UV treatment; • Tint (fashion, gradient, and glass- grey) • Standard plastic scratch coating; • Standard polycarbonate; • Photocromatic/ transitions plastic Contact Lens One supply of collection contact lenses (Extended Wear OR Daily Wear OR Conventional) covered in lieu of Prescription glasses. Includes evaluation, fitting or follow-up care relating to contact lenses. Non-collection contact lenses are NOT covered. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? The following contact lenses are covered: • Extended Wear Disposables are covered up to the benefit limit of a six (6) month supply of monthly or two (2) week disposables in a benefit year. • Daily Wear Disposable are covered up to the benefit limit of a three (3) month supply of daily disposable lenses in a benefit year. • Conventional contact lens limited to one per benefit year. 0% NO Not Covered Not Covered One additional supply (as indicated above) of contact lenses may be covered for certain conditions: • Anisometropia • High Ametropia • Keratoconus • Vision improvement for members whose 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? vision can be corrected two lines of improvement. Preauthorization recommended. Prescription drugs for which preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. • Prescription drugs - ask your prescribing physician to call the number listed for the “Pharmacist” on the back of your ID card. To see if prescription drug requires preauthorization, call our Customer Service Department or visit our Web site.:

Appears in 1 contract

Sources: Subscriber Agreement

Early Intervention Services (EIS). For children from birth to 36 months The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% ~~YES 0% The level of coverage is the same as network provider. YES~~ NO The level of coverage is the same as network provider. Education Asthma Management 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam 0% YES Not Covered Not Covered Diagnostic Testing 0% YES Not Covered Not Covered Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 0% YES The level of coverage is the same as network provider. Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered Coverage varies based on type of hemophilia service. Home Health Care In your home Intermittent skilled services when billed by a home health care agency. 0% YES Not Covered Not Covered Prescription drug Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Coverage varies based on type of hemophilia service. 0% YES Not Covered Not Covered Home Health Care In your home Intermittent skilled services when billed by a home health care agency. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. 0% YES The level of coverage is the same as network provider. Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 0% YES Not Covered Not Covered Testing Infertility Inpatient/ outpatient/in a doctor’s office Three (3) infertility treatment cycles will be covered per benefit year with a total of eight (8) infertility treatment 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Infertility Inpatient/ outpatient/in a doctor’s office Three (3) infertility treatment cycles will be covered per benefit year with a total of eight (8) infertility treatment cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 0% YES Not Covered Not Covered Inpatient Physician Hospital Visits Inpatient 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 0% YES Not Covered Not Covered Inpatient Physician Hospital Visits Inpatient 0% YES Not Covered Not Covered Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 0% YES Not Covered Not Covered Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist ~~0% YES~~ $30 NO Not Covered Not Covered Hospital based clinic visits for adults ~~0% YES~~ $30 NO Not Covered Not Covered House Calls rendered by ~~personal~~ primary care physician ▇▇▇▇ ▇▇▇▇▇ First, second, or third submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visitsPCP practices with PCMH model of care. $25 15 NO Not Covered Not Covered ~~Subsequent submitted claims for sick office visits in a benefit year~~PCP does not practice with PCMH model of care. ~~0% YES~~ $25 NO House Calls rendered by Specialist ~~0% YES Not Covered Not Covered Pediatric Clinic visit Sick Visit First, second, or third~~ $25 30 NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? ~~submitted claim for a sick office visit in a benefit year. Benefit limit applies to all~~ Office Visits (other than office visits ~~rendered by a PCP, except the~~ for Behavioral Health and annual preventive ~~care office visits. Subsequent submitted claims for sick~~ care) (continued) Pediatric Clinic visit PCP practices with PCMH model of care- subsequent office visits in ~~a benefit~~ calendar year. ~~0% YES Personal~~ $15 NO Not Covered Not Covered PCP does not practice with PCMH model of care. $25 NO Primary Care Physician (PCP) See Prevention and Early Detection Services for coverage of annual preventive office visit. Sick Visit First, second, or third submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visitsPCP practices with PCMH model of care. $25 15 NO Not Covered Not Covered ~~Subsequent submitted claims~~ PCP does not practice with PCMH model of care. $25 NO Podiatrist Services Routine foot care is not covered. $30 NO Not Covered Not Covered Retail Clinics See Section 3.23 – Office Visits for ~~sick office visits in a benefit year~~details. $30 NO Not Covered Not Covered Specialist Visits Routine and non- routine visits. $30 NO Not Covered Not Covered Organ Transplants 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Podiatrist Services Routine foot care is not covered. 0% YES Not Covered Not Covered Specialist Visits Routine and non-routine visits. 0% YES Not Covered Not Covered Organ Transplants 0% YES Not Covered Not Covered Physical/ Occupational Therapy * Outpatient hospital/In a doctor’s/ therapist’s office ~~Preauthorization is recommended for the eleventh (11th) and subsequent visits. 0% YES Not Covered Not Covered~~ Covered health care services include rehabilitative and habilitative services. 0% YES Not Covered Not Covered Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 0% YES Not Covered Not Covered Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 0% YES Not Covered Not Covered Infused drugs 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: ~~provider (other than a pharmacist)~~ Your copayment Does the deductible apply? Your copayment Does the deductible apply? Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details. Prevention and Early Detection Services Adult annual preventive visit One (1) routine adult physical examination per benefit year per member will be covered. 0% NO Not Covered Not Covered Well woman annual preventive visit One (1) routine gynecological examination per benefit year per female member will be covered. 0% NO Not Covered Not Covered Pediatric preventive office visit Well-Child Office Visits: Birth - 15 months: 8 visits; 16 - 35 months: 3 visits; 36 months - 19 years: 1 per benefit year. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Pediatric preventive clinic 0% NO Not Covered Not Covered Diabetes education Individual and group sessions are covered. 0% NO Not Covered Not Covered Nutritional counseling Unlimited visits per benefit year when prescribed by a physician. 0% NO Not Covered Not Covered Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO Not Covered Not Covered Adult Immunization 0% NO Not Covered Not Covered Pediatric Immunization 0% NO Not Covered Not Covered Travel Immunization 0% NO Not Covered Not Covered Allergy injections Applies to injection only including administration. 0% YES Not Covered Not Covered Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. Prevention and Early Detection Services Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO Not Covered Not Covered Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO Not Covered Not Covered Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO Not Covered Not Covered Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Manual breast pumps In conjunction with birth. 0% NO Not Covered Not Covered Private Duty Nursing 0% YES Not Covered Not Covered Radiation Therapy/ Chemotherapy Services Outpatient 0% YES Not Covered Not Covered In a doctor’s office 0% YES Not Covered Not Covered Respiratory Therapy 0% YES Not Covered Not Covered Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES Not Covered Not Covered Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 0% YES Not Covered Not Covered Surgery Services Inpatient 0% YES Not Covered Not Covered Outpatient 0% YES Not Covered Not Covered In a doctor’s office 0% YES Not Covered Not Covered Tests, Imaging*, and Labs (includes machine tests and x-rays) Outpatient Hospital Facility/ Outpatient Non- Hospital facility including in a Doctor’s office, urgent care Applies to the following diagnostic imaging services: • MRI; • MRA; • CAT scans; • CTA scans; 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? center, or free- standing laboratory • PET scans; and • Nuclear Cardiac Imaging. Preauthorization is recommended for these diagnostic imaging services. For tests, imaging and lab, other than the diagnostic imaging services listed above. 0% YES Not Covered Not Covered Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services - Preventive Screening for preventive colorectal services. 0% YES Not Covered Not Covered Lyme Disease- Diagnosis/ Treatment 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Urgent care facility Urgent care facility/walk-in See Section 8.0 - definition of urgent care center. 0% YES The level of coverage is the same as network provider. Vision care services Eye Exam In a doctor’s office One routine eye exam per benefit year, including one pediatric vision exam for a member up to age 19. Medically necessary eye exams are covered. 0% YES Not Covered Not Covered Vision Hardware for a member aged 19 and older Not Covered Not Covered Not Covered Not Covered Vision Hardware for a member under the age of 19 Prescription glasses - Frames One pair of collection prescription frames per benefit year. Non-collection prescription frames are NOT covered. 0% NO Not Covered Not Covered One pair of glass or plastic lenses per benefit year. This includes single vision, bifocal, trifocal, 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? lenticular, and standard progressive lens. The following lens treatments are covered: • UV treatment; • Tint (fashion, gradient, and glass- grey) • Standard plastic scratch coating; • Standard polycarbonate; • Photocromatic/ transitions plastic Contact Lens One supply of collection contact lenses (Extended Wear OR Daily Wear OR Conventional) covered in lieu of Prescription glasses. Includes evaluation, fitting or follow-up care relating to contact lenses. Non-collection contact lenses are NOT covered. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? The following contact lenses are covered: • Extended Wear Disposables are covered up to the benefit limit of a six (6) month supply of monthly or two (2) week disposables in a benefit year. • Daily Wear Disposable are covered up to the benefit limit of a three (3) month supply of daily disposable lenses in a benefit year. • Conventional contact lens limited to one per benefit year. 0% NO Not Covered Not Covered One additional supply (as indicated above) of contact lenses may be covered for certain conditions: • Anisometropia • High Ametropia • Keratoconus • Vision improvement for members whose 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? vision can be corrected two lines of improvement. Preauthorization recommended. Prescription drugs for which preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. • Prescription drugs - ask your prescribing physician to call the number listed for the “Pharmacist” on the back of your ID card. To see if prescription drug requires preauthorization, call our Customer Service Department or visit our Web site.

Appears in 1 contract

Sources: Subscriber Agreement

Early Intervention Services (EIS). For children from birth to 36 months The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% ~~YES 0% The level of coverage is the same as network provider. YES~~ NO The level of coverage is the same as network provider. Education Asthma Management 0$0 NO 40% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam 0$40 NO 40% YES ~~Not Covered Not Covered~~ Diagnostic Testing 020% YES Not Covered Not Covered Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 0% YES The level of coverage is the same as network provider. Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered Coverage varies based on type of hemophilia service. Home Health Care In your home Intermittent skilled services when billed by a home health care agency. 0% YES Not Covered Not Covered Prescription drug Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. 0% YES The level of coverage is the same as network provider. Human Leukocyte Antigen Human Leukocyte Antigen Testing 0% YES Not Covered Not Covered Testing Infertility Inpatient/ outpatient/in a doctor’s office Three (3) infertility treatment cycles will be covered per benefit year with a total of eight (8) infertility treatment 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 0% YES Not Covered Not Covered Inpatient Physician Hospital Visits Inpatient 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 0% YES Not Covered Not Covered Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist 0% YES Not Covered Not Covered Hospital based clinic visits for adults 0% YES Not Covered Not Covered House Calls rendered by personal care physician ▇▇▇▇ ▇▇▇▇▇ First, second, or third submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visits. $25 NO Not Covered Not Covered Subsequent submitted claims for sick office visits in a benefit year. 0% YES House Calls rendered by Specialist 0% YES Not Covered Not Covered Pediatric Clinic visit Sick Visit First, second, or third $25 NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visits. Subsequent submitted claims for sick office visits in a benefit year. 0% YES Personal Care Physician (PCP) See Prevention and Early Detection Services for coverage of annual preventive office visit. Sick Visit First, second, or third submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visits. $25 NO Not Covered Not Covered Subsequent submitted claims for sick office visits in a benefit year. 040% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: ~~Your copayment Does the deductible apply? Your copayment Does the deductible apply? Podiatrist Services Routine foot care is not covered~~Hearing Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 020% YES ~~Not Covered Not Covered Specialist Visits Routine~~ The level of coverage is the same as network provider. Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and ~~non-routine visits~~site of service. 0See Summary of Pharmacy 20% YES ~~Not Covered Not Covered Organ Transplants 0~~40% YES ~~Not Covered Not Covered Physical/ Occupational Therapy * Outpatient hospital/~~Benefits for details. Coverage varies based on type of hemophilia service. Home Health Care In your home Intermittent skilled services when billed by a ~~doctor’s/ therapist’s office Preauthorization~~ home health care agency. Prescription drug coverage benefit level is ~~recommended for the eleventh (11th) and subsequent visits. 0~~based on type 20% YES ~~Not Covered Not Covered Covered health care services include rehabilitative and habilitative services. Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 0~~40% YES ~~Not Covered Not Covered~~ of service and site of service. See Summary of Pharmacy Benefits for details. Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 0drug coverage benefit level is based on type 20% YES ~~Not Covered Not Covered Infused drugs 0~~40% YES ~~Not Covered Not Covered~~ of service and site of service. See Summary of Pharmacy Benefits for details. Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: ~~provider~~ Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. $200 NO The level of coverage is the same as network provider. Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 20% YES 40% YES Infertility Inpatient/ outpatient/in a doctor’s office Three (~~other than~~ 3) infertility treatment cycles will be covered per benefit year with a ~~pharmacist)~~ total of eight (8) infertility treatment cycles covered in a member’s lifetime. Prescription ~~Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy~~ drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. ~~Prevention~~ 20% YES 20% YES Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and ~~Early Detection Services Adult annual preventive visit One (1) routine adult physical examination per~~ site of service. See Summary of Pharmacy Benefits for details. 20% YES 40% YES In the doctor’s office/in your home Prescription drug coverage benefit ~~year per member will be covered~~level is based on type of service and site of service. 0See Summary of Pharmacy Benefits for details. 20% ~~NO Not Covered Not Covered Well woman annual preventive visit One (1) routine gynecological examination per benefit year per female member will be covered. 0~~YES 40% NO Not Covered Not Covered Pediatric preventive office visit Well-Child Office Visits: Birth - 15 months: 8 visits; 16 - 35 months: 3 visits; 36 months - 19 years: 1 per benefit year. 0% NO Not Covered Not Covered YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: ~~Your copayment Does the deductible apply? Your copayment Does the deductible apply? Pediatric preventive clinic 0~~Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 20% ~~NO Not Covered Not Covered Diabetes education Individual and group sessions are covered. 0~~YES 40% ~~NO Not Covered Not Covered Nutritional counseling Unlimited visits~~ YES Inpatient Physician Hospital Visits Inpatient 20% YES 40% YES Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit ~~year when prescribed~~ year. 20% YES 40% YES Office Visits (other than office visits for Behavioral Health and annual preventive care) Allergist & Dermatologist $40 NO 40% YES Hospital based clinic visits for adults $40 NO 40% YES House Calls rendered by primary care physician PCP practices with PCMH model of care. $15 NO 40% YES PCP does NOT practice with PCMH model of care. For a ~~physician. 0%~~ member under nineteen (19) $15 NO ~~Not Covered Not Covered Smoking cessation counseling~~ For ~~nicotine replacement therapy~~ a member nineteen (~~NRT~~19) and ~~smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0%~~ older $25 NO ~~Not Covered Not Covered Adult Immunization 0%~~ House Calls rendered by Specialist $40 NO ~~Not Covered Not Covered Pediatric Immunization 0% NO Not Covered Not Covered Travel Immunization 0% NO Not Covered Not Covered Allergy injections Applies to injection only including administration. 0~~40% YES ~~Not Covered Not Covered Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, 0~~Pediatric Clinic visit PCP practices with PCMH model of care. $15 NO 40% YES PCP does NOT practice with PCMH model of care. For a member under nineteen (19) $15 NO ~~Not Covered Not Covered~~ Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: ~~Your copayment Does~~ Office Visits (other than office visits for Behavioral Health and annual preventive care) Pediatric Clinic visit For a member nineteen (19) and older $25 NO Primary Care Physician (PCP) PCP practices with PCMH model of care. $15 NO 40% YES PCP does NOT practice with PCMH model of care. For a member under nineteen (19) $15 NO For a member nineteen (19) and older $25 NO Podiatrist Services Routine foot care is not covered. $40 NO 40% YES Specialist Visits Routine and non- routine visits. $40 NO 40% YES Organ Transplants 20% YES 40% YES Physical/ Occupational Therapy Outpatient hospital/In a doctor’s/ therapist’s office Preauthorization is recommended for the ~~deductible apply? Your copayment Does the deductible apply? flexible sigmoidoscopy~~eleventh (11th) and subsequent visits. Covered health care services include rehabilitative and habilitative services. 20% YES 40% YES Pregnancy Services and Nursery Care Pre-natal, ~~colonoscopy, double contrast barium enema~~delivery, and ~~fecal occult blood tests, screening for gestational diabetes, and human papillomavirus~~postpartum services. ~~Prevention and Early Detection Services Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0~~20% ~~NO Not Covered Not Covered Contraceptive and Sterilization Services for women~~ YES 40% YES Prescription drugs, ~~dispensed and administered by a licensed health care provider (~~other than ~~a pharmacist)~~Specialty Medications other than injected and infused drugs. ~~For prescription drugs purchased at a pharmacy, see~~ Are included in the ~~Summary of Pharmacy Benefits~~allowance for the medical service being rendered. 0% NO Not Covered Not Covered Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO Not Covered Not Covered Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: ~~Your copayment Does the deductible apply? Your copayment Does the deductible apply? Manual breast pumps In conjunction with birth. 0% NO Not Covered Not Covered Private Duty Nursing 0~~Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Injectable drugs 20% YES ~~Not Covered Not Covered Radiation Therapy/ Chemotherapy Services Outpatient 0~~40% YES ~~Not Covered Not Covered In a doctor’s office 0~~Infused drugs 20% YES ~~Not Covered Not Covered Respiratory Therapy 0~~40% YES ~~Not Covered Not Covered Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES Not Covered Not Covered Speech Therapy* Outpatient/in~~ Prescription Drugs Purchased at a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 0% YES Not Covered Not Covered Surgery Services Inpatient 0% YES Not Covered Not Covered Outpatient 0% YES Not Covered Not Covered In a doctor’s office 0% YES Not Covered Not Covered TestsRetail, Imaging*, and Labs (includes machine tests and x-rays) Outpatient Hospital Facility/ Outpatient Non- Hospital facility including in a Doctor’s office, urgent care Applies to the following diagnostic imaging services: • MRI; • MRA; • CAT scans; • CTA scans; 0% YES Not Covered Not Covered Service Service Type, ProviderSpecialty, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? center, or free- standing laboratory • PET scans; and • Nuclear Cardiac Imaging. Preauthorization is recommended for these diagnostic imaging services. For tests, imaging and lab, other than the diagnostic imaging services listed above. 0% YES Not Covered Not Covered Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. Mail Order Pharmacy See Prevention and Early Detection Services - Preventive Screening for preventive colorectal services. 0% YES Not Covered Not Covered Lyme Disease- Diagnosis/ Treatment 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Urgent care facility Urgent care facility/walk-in See Section 8.0 - definition of urgent care center. 0% YES The level of coverage is the same as network provider. Vision care services Eye Exam In a doctor’s office One routine eye exam per benefit year, including one pediatric vision exam for a member up to age 19. Medically necessary eye exams are covered. 0% YES Not Covered Not Covered Vision Hardware for a member aged 19 and older Not Covered Not Covered Not Covered Not Covered Vision Hardware for a member under the age of 19 Prescription glasses - Frames One pair of collection prescription frames per benefit year. Non-collection prescription frames are NOT covered. 0% NO Not Covered Not Covered One pair of glass or plastic lenses per benefit year. This includes single vision, bifocal, trifocal, 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? lenticular, and standard progressive lens. The following lens treatments are covered: • UV treatment; • Tint (fashion, gradient, and glass- grey) • Standard plastic scratch coating; • Standard polycarbonate; • Photocromatic/ transitions plastic Contact Lens One supply of collection contact lenses (Extended Wear OR Daily Wear OR Conventional) covered in lieu of Prescription glasses. Includes evaluation, fitting or follow-up care relating to contact lenses. Non-collection contact lenses are NOT covered. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? The following contact lenses are covered: • Extended Wear Disposables are covered up to the benefit limit of a six (6) month supply of monthly or two (2) week disposables in a benefit year. • Daily Wear Disposable are covered up to the benefit limit of a three (3) month supply of daily disposable lenses in a benefit year. • Conventional contact lens limited to one per benefit year. 0% NO Not Covered Not Covered One additional supply (as indicated above) of contact lenses may be covered for certain conditions: • Anisometropia • High Ametropia • Keratoconus • Vision improvement for members whose 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? vision can be corrected two lines of improvement. Preauthorization recommended. Prescription drugs for which preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy ~~Benefits. • Prescription drugs - ask your prescribing physician to call the number listed~~ Benefits for ~~the “Pharmacist” on the back of your ID card. To see if prescription drug requires preauthorization, call our Customer Service Department or visit our Web site~~details.

Appears in 1 contract

Sources: Subscriber Agreement

Early Intervention Services (EIS). For children from birth to 36 months The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% YES ~~0% The level of coverage is the same as network provider. YES~~ The level of coverage is the same as network provider. Education Asthma Management 0% YES Not Covered Not Covered Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Hearing Exam 0% YES Not Covered Not Covered Diagnostic Testing 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: ~~Experimental/ Investigational Services Coverage varies based on type of service. Hearing Hearing Exam 0% YES Not Covered Not Covered Diagnostic Testing 0% YES Not Covered Not Covered~~ Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear per hearing aid for a member 19 and older. 0% YES The level of coverage is the same as network provider. Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered Coverage varies based on type of hemophilia service. Home Health Care In your home Intermittent skilled services when billed by a home health care agency. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered ~~Prescription drug~~ Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Hospice Care Inpatient/in your home When provided by an approved hospice care program. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency. 0% YES The level of coverage is the same as network provider. Human Leukocyte Antigen Testing Human Leukocyte Antigen Testing 0% YES Not Covered Not Covered ~~Testing~~ Infertility Inpatient/ outpatient/in a doctor’s office Three (3) infertility treatment cycles will be covered per benefit year with a total of eight (8) infertility treatment cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Infusion Therapy Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered In the doctor’s office/in your home Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. 0% YES Not Covered Not Covered Inpatient Hospital Services Inpatient* Unlimited days at general hospital or a specialty hospital. 0% YES Not Covered Not Covered Inpatient Physician Hospital Visits Inpatient 0% YES Not Covered Not Covered Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 0% YES Not Covered Not Covered Office Visits (other than office visits for Behavioral Health and annual preventive care) Office Visits Allergist & Dermatologist 0% YES Not Covered Not Covered Hospital based clinic visits for adults 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: ~~Inpatient Rehabilitation Facility Inpatient* Maximum of 45 days per benefit year. 0% YES Not Covered Not Covered Office Visits~~ (other than office visits for Behavioral Health and annual preventive care) ~~Allergist & Dermatologist 0% YES Not Covered Not Covered Hospital based clinic visits for adults 0% YES Not Covered Not Covered~~ House Calls rendered by ~~personal care physician ▇▇▇▇ ▇▇▇▇▇~~ Primary Care Physician Sick Visit First, second, or third submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visits. $25 NO Not Covered Not Covered Subsequent submitted claims for sick office visits in a benefit year. 0% YES Not Covered Not Covered House Calls rendered by Specialist 0% YES Not Covered Not Covered Pediatric Clinic visit Sick Visit First, second, or third submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visits. $25 NO Not Covered Not Covered Office Visits (other than Subsequent submitted claims for sick office visits in a benefit year. 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: ~~Your copayment Does the deductible apply? Your copayment Does the deductible apply? submitted claim for a sick office visit in a benefit year. Benefit limit applies to all~~ office visits ~~rendered by a PCP, except the~~ for Behavioral Health and annual preventive ~~care office visits. Subsequent submitted claims for sick office visits in a benefit year. 0% YES Personal~~ care) Primary Care Physician (PCP) See Prevention and Early Detection Services for coverage of annual preventive office visit. Sick Visit First, second, or third submitted claim for a sick office visit in a benefit year. Benefit limit applies to all office visits rendered by a PCP, except the annual preventive care office visits. $25 NO Not Covered Not Covered Subsequent submitted claims for sick office visits in a benefit year. 0% YES Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Not Covered Not Covered Podiatrist Services Routine foot care is not covered. 0% YES Not Covered Not Covered Specialist Visits Routine and ~~non-~~non- routine visits. 0% YES Not Covered Not Covered Organ Transplants 0% YES Not Covered Not Covered Physical/ Occupational Therapy * Outpatient hospital/In a doctor’s/ therapist’s office Preauthorization is recommended for the eleventh (11th) and subsequent visits. ~~0% YES Not Covered Not Covered~~ Covered health care services include rehabilitative and habilitative services. Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 0% YES Not Covered Not Covered Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 0% YES Not Covered Not Covered Infused drugs 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Pregnancy Services and Nursery Care Pre-natal, delivery, and postpartum services. 0% YES Not Covered Not Covered Prescription drugs, other than Specialty Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist) Medications other than injected and infused drugs. Are included in the allowance for the medical service being rendered. Injectable drugs 0% YES Not Covered Not Covered Infused drugs 0% YES Not Covered Not Covered Prescription Drugs Purchased at a Retail, Specialty, or Mail Order Pharmacy See Summary of Pharmacy Benefits for details. Prevention and Early Detection Services Adult annual preventive visit One (1) routine adult physical examination per benefit year per member will be covered. 0% NO Not Covered Not Covered Well woman annual preventive visit One (1) routine gynecological examination per benefit year per female member will be covered. 0% NO Not Covered Not Covered Pediatric preventive office visit Well-Child Office Visits: Birth - 15 months: 8 visits; 16 - 35 months: 3 visits; 36 months - 19 years: 1 per benefit year. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Pediatric preventive clinic 0% NO Not Covered Not Covered Diabetes education Individual and group sessions are covered. 0% NO Not Covered Not Covered Nutritional counseling Unlimited visits per benefit year when prescribed by a physician. 0% NO Not Covered Not Covered Smoking cessation counseling For nicotine replacement therapy (NRT) and smoking cessation prescription drugs, see the Summary of Pharmacy Benefits. 0% NO Not Covered Not Covered Adult Immunization 0% NO Not Covered Not Covered Pediatric Immunization 0% NO Not Covered Not Covered Travel Immunization 0% NO Not Covered Not Covered Allergy injections Applies to injection only including administration. 0% YES Not Covered Not Covered Preventive screenings Coverage includes, but is not limited to, the following: mammograms, pap smear, PSA test, 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? flexible sigmoidoscopy, colonoscopy, double contrast barium enema, and fecal occult blood tests, screening for gestational diabetes, and human papillomavirus. Prevention and Early Detection Services Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO Not Covered Not Covered Contraceptive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO Not Covered Not Covered Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO Not Covered Not Covered Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Manual breast pumps In conjunction with birth. 0% NO Not Covered Not Covered Private Duty Nursing 0% YES Not Covered Not Covered Radiation Therapy/ Chemotherapy Services Outpatient 0% YES Not Covered Not Covered In a doctor’s office 0% YES Not Covered Not Covered Respiratory Therapy 0% YES Not Covered Not Covered Skilled Nursing Facility Care* Skilled or Sub- acute 0% YES Not Covered Not Covered Speech Therapy* Outpatient/in a doctor’s/ therapist’s office Covered health care services include rehabilitative and habilitative services. 0% YES Not Covered Not Covered Surgery Services Inpatient 0% YES Not Covered Not Covered Outpatient 0% YES Not Covered Not Covered In a doctor’s office 0% YES Not Covered Not Covered Tests, Imaging*, and Labs (includes machine tests and x-rays) Outpatient Hospital Facility/ Outpatient Non- Hospital facility including in a Doctor’s office, urgent care Applies to the following diagnostic imaging services: • MRI; • MRA; • CAT scans; • CTA scans; 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? center, or free- standing laboratory • PET scans; and • Nuclear Cardiac Imaging. Preauthorization is recommended for these diagnostic imaging services. For tests, imaging and lab, other than the diagnostic imaging services listed above. 0% YES Not Covered Not Covered Diagnostic colorectal services Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services - Preventive Screening for preventive colorectal services. 0% YES Not Covered Not Covered Lyme Disease- Diagnosis/ Treatment 0% YES Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Urgent care facility Urgent care facility/walk-in See Section 8.0 - definition of urgent care center. 0% YES The level of coverage is the same as network provider. Vision care services Eye Exam In a doctor’s office One routine eye exam per benefit year, including one pediatric vision exam for a member up to age 19. Medically necessary eye exams are covered. 0% YES Not Covered Not Covered Vision Hardware for a member aged 19 and older Not Covered Not Covered Not Covered Not Covered Vision Hardware for a member under the age of 19 Prescription glasses - Frames One pair of collection prescription frames per benefit year. Non-collection prescription frames are NOT covered. 0% NO Not Covered Not Covered One pair of glass or plastic lenses per benefit year. This includes single vision, bifocal, trifocal, 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? lenticular, and standard progressive lens. The following lens treatments are covered: • UV treatment; • Tint (fashion, gradient, and glass- grey) • Standard plastic scratch coating; • Standard polycarbonate; • Photocromatic/ transitions plastic Contact Lens One supply of collection contact lenses (Extended Wear OR Daily Wear OR Conventional) covered in lieu of Prescription glasses. Includes evaluation, fitting or follow-up care relating to contact lenses. Non-collection contact lenses are NOT covered. 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? The following contact lenses are covered: • Extended Wear Disposables are covered up to the benefit limit of a six (6) month supply of monthly or two (2) week disposables in a benefit year. • Daily Wear Disposable are covered up to the benefit limit of a three (3) month supply of daily disposable lenses in a benefit year. • Conventional contact lens limited to one per benefit year. 0% NO Not Covered Not Covered One additional supply (as indicated above) of contact lenses may be covered for certain conditions: • Anisometropia • High Ametropia • Keratoconus • Vision improvement for members whose 0% NO Not Covered Not Covered Service Service Type, Provider, or Place of Service Benefit Limit Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? vision can be corrected two lines of improvement. Preauthorization recommended. Prescription drugs for which preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. • Prescription drugs - ask your prescribing physician to call the number listed for the “Pharmacist” on the back of your ID card. To see if prescription drug requires preauthorization, call our Customer Service Department or visit our Web site.

Appears in 1 contract

Sources: Subscriber Agreement

Common use of Early Intervention Services (EIS) Clause in Contracts