Emergency services Emergency room services. If admitted to the Hospital, this payment for emergency room services does not apply. Instead, you pay the Participating Provider payment under Inpatient facility services/ Hospital services and stay. Emergency room Physician services 10% 10% 10% 10% When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Urgent care center services 10% 30% Ambulance services This payment is for emergency or authorized transport. 10% 10% Outpatient facility services Ambulatory Surgery Center 10% 30% of up to $350/day plus 100% of additional charges Outpatient Department of a Hospital: surgery 10% 30% of up to $350/day plus 100% of additional charges Outpatient Department of a Hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies 10% 30% of up to $350/day plus 100% of additional charges Inpatient facility services Hospital services and stay Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies. Special transplant facility inpatient services Physician inpatient services 10% 10% 10% 30% of up to $1,000/day plus 100% of additional charges Not covered Not covered Bariatric surgery services, designated California counties This payment is for bariatric surgery services for residents of designated California counties. For bariatric surgery services for residents of non- designated California counties, the payments for Inpatient facility services/ Hospital services and stay and Physician inpatient and surgery services apply for inpatient services; or, if provided on an outpatient basis, the outpatient facility services and Outpatient Physician services payments apply. Inpatient facility services 10% Not covered Outpatient facility services 10% Not covered Physician services When using a Participating Provider3 10% CYD2 applies When using a Non-Participating Provider4 Not covered CYD2 applies Diagnostic x-ray, imaging, pathology, and laboratory services This payment is for Covered Services that are diagnostic, non-Preventive Health Services, and diagnostic radiological procedures, such as CT scans, MRIs, MRAs, and PET scans. For the payments for Covered Services that are considered Preventive Health Services, see Preventive Health Services. Laboratory services Includes diagnostic Papanicolaou (Pap) test. Laboratory center 10% 30% 30% of up to $350/day Outpatient Department of a Hospital 10% plus 100% of additional charges X-ray and imaging services Includes diagnostic mammography. Outpatient radiology center 10% 30% 30% of up to $350/day Outpatient Department of a Hospital 10% plus 100% of additional charges Other outpatient diagnostic testing Testing to diagnose illness or injury such as vestibular function tests, EKG, ECG, cardiac monitoring, non-invasive vascular studies, sleep medicine testing, muscle and range of motion tests, EEG, and EMG. Office location 10% 30% 30% of up to $350/day Outpatient Department of a Hospital 10% plus 100% of additional charges Radiological and nuclear imaging services Outpatient radiology center 10% 30% 30% of up to $350/day Outpatient Department of a Hospital 10% plus 100% of additional charges When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Rehabilitative and Habilitative Services Includes physical therapy, occupational therapy, respiratory therapy, and speech therapy services. Office location 10% Outpatient Department of a Hospital 10% 30% 30% of up to $350/day plus 100% of additional charges Durable medical equipment (DME) 30% 30% 30% 30% DME 10% Breast pump $0 Orthotic equipment and devices 10% Prosthetic equipment and devices 10% Home health care services 10% Up to 100 visits per Member, per Calendar Year, by a home health care agency. All visits count towards the limit, including visits during any applicable Deductible period. Includes home visits by a nurse, Home Health Aide, medical social worker, physical therapist, speech therapist, or occupational therapist, and medical supplies. Not covered Home infusion and home injectable therapy services Home infusion agency services 10% Includes home infusion drugs and medical supplies. Home visits by an infusion nurse 10% Hemophilia home infusion services 10% Includes blood factor products. Not covered Not covered Not covered Skilled Nursing Facility (SNF) services Up to 100 days per Member, per Benefit Period, except when provided as part of a Hospice program. All days count towards the limit, including days during any applicable Deductible period and days in different SNFs during the Calendar Year. Freestanding SNF 10% Hospital-based SNF 10% 50% 30% of up to $1,000/day plus 100% of additional charges When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Hospice program services Includes pre-Hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care. $0 Not covered Other services and supplies Diabetes care services Devices, equipment, and supplies Self-management training Dialysis services PKU product formulas and Special Food Products Allergy serum billed separately from an office visit Hearing services Hearing aids and equipment 10% 10% 10% 10% 10% 20% 30% 30% 30% of up to $350/day plus 100% of additional charges 10% 30% 20%
Appears in 1 contract
Samples: www.scu.edu
Emergency services Emergency room services. If admitted to the Hospital, this payment for emergency room services does not apply. Instead, you pay the Participating Provider payment under Inpatient facility services/ Hospital services and stay. Emergency room Physician services 10$150/visit plus 20% 20% 10$150/visit plus 20% 10% 1020% When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Urgent care center services 1020% 3050% Ambulance services This payment is for emergency or authorized transport. 1020% 1020% Outpatient facility services Ambulatory Surgery Center 10% 3050% of up to $350/day plus 100% of additional charges Outpatient Department of a Hospital: surgery 1020% 3050% of up to $350/day plus 100% of additional charges Outpatient Department of a Hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies 1020% 3050% of up to $350/day plus 100% of additional charges Inpatient facility services Hospital services and stay Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies. Special transplant facility inpatient services Physician inpatient services 1020% 1020% 1020% 3050% of up to $1,000600/day plus 100% of additional charges Not covered Not covered Bariatric surgery services, designated California counties This payment is for bariatric surgery services for residents of designated California counties. For bariatric surgery services for residents of non- designated California counties, the payments for Inpatient facility services/ Hospital services and stay and Physician inpatient and surgery services apply for inpatient services; or, if provided on an outpatient basis, the outpatient facility services and Outpatient Physician services payments apply. Inpatient facility services 1020% Not covered Outpatient facility services 1020% Not covered Physician services When using a Participating Provider3 10% CYD2 applies When using a Non-Participating Provider4 CYD2 applies Physician services 20% Not covered CYD2 applies Diagnostic x-ray, imaging, pathology, and laboratory services This payment is for Covered Services that are diagnostic, non-Preventive Health Services, and diagnostic radiological procedures, such as CT scans, MRIs, MRAs, and PET scans. For the payments for Covered Services that are considered Preventive Health Services, see Preventive Health Services. Laboratory services Includes diagnostic Papanicolaou (Pap) test. Laboratory center 1020% 3050% 3050% of up to $350/day Outpatient Department of a Hospital 1030% plus 100% of additional charges X-ray and imaging services Includes diagnostic mammography. Outpatient radiology center 1020% 3050% 3050% of up to $350/day Outpatient Department of a Hospital 1030% plus 100% of additional charges Other outpatient diagnostic testing Testing to diagnose illness or injury such as vestibular function tests, EKG, ECG, cardiac monitoring, non-invasive vascular studies, sleep medicine testing, muscle and range of motion tests, EEG, and EMG. Office location 1020% 3050% 3050% of up to $350/day Outpatient Department of a Hospital 1030% plus 100% of additional charges Radiological and nuclear imaging services Outpatient radiology center 1020% 3050% 3050% of up to $350/day Outpatient Department of a Hospital 10$100/visit plus 20% plus 100% of additional charges When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Rehabilitative and Habilitative Services Includes physical therapyPhysical Therapy, occupational therapyOccupational Therapy, respiratory therapyRespiratory Therapy, and speech therapy Speech Therapy services. Office location 1020% Outpatient Department of a Hospital 1020% 50% 30% 3050% of up to $350/day plus 100% of additional charges Durable medical equipment (DME) 3050% 30Not covered 50% 30% 3050% DME 1020% Breast pump $0 Orthotic equipment and devices 1020% Prosthetic equipment and devices 1020% Home health care services 1020% Up to 100 visits per Member, per Calendar Year, by a home health care agency. All visits count towards the limit, including visits during any applicable Deductible period. Includes home visits by a nurse, Home Health Aide, medical social worker, physical therapist, speech therapist, or occupational therapist, and medical supplies. Not covered Home infusion and home injectable therapy services Home infusion agency services 1020% Includes home infusion drugs and medical supplies. Home visits by an infusion nurse 1020% Hemophilia home infusion services 1020% Includes blood factor products. Not covered Not covered Not covered Skilled Nursing Facility (SNF) services Up to 100 days per Member, per Benefit Period, except when provided as part of a Hospice program. All days count towards the limit, including days during any applicable Deductible period and days in different SNFs during the Calendar Year. Freestanding SNF 1020% Hospital-based SNF 1020% 50% 3050% of up to $1,000600/day plus 100% of additional charges When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Hospice program services Includes pre-Hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care. $0 Not covered Other services and supplies Diabetes care services Devices, equipment, and supplies Self-management training Dialysis services PKU product formulas and Special Food Products Allergy serum billed separately from an office visit Hearing services Hearing aids and equipment 1020% 1020% 1020% 10% 1020% 20% 3050% 3050% 3050% of up to $350/day plus 100% of additional charges 1020% 30% 2050%
Appears in 1 contract
Samples: www.mrstaxbenefits.com
Emergency services Emergency room services. If admitted to the Hospital, this payment for emergency emer- gency room services does not apply. Instead, you pay the Participating Provider payment under Inpatient In- patient facility services/ Hospital services and stay. Emergency room Physician services 10$150/visit plus 20% 1020% 10$150/visit plus 20% 1020% Benefits6 Your payment When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Urgent care center services 10% 30$35/visit 40% Ambulance services This payment is for emergency or authorized transport. 1020% 1020% Outpatient facility services Ambulatory Surgery Center 10% 3040% of up to $350/day plus 100% of additional addi- tional charges Outpatient Department of a Hospital: surgery 1025% 3040% of up to $350/day plus 100% of additional addi- tional charges Outpatient Department of a Hospital: treatment of illness ill- ness or injury, radiation therapy, chemotherapy, and necessary supplies 1020% 3040% of up to $350/day plus 100% of additional addi- tional charges Inpatient facility services Hospital services and stay Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies. Special transplant facility inpatient services Physician inpatient services 1020% 1020% 1020% 3040% of up to $1,000600/day plus 100% of additional addi- tional charges Not covered Not covered Bariatric surgery services, designated California counties Not covered Not covered Not covered This payment is for bariatric surgery services for residents of designated California counties. For bariatric surgery services for residents of non- non-designated California counties, the payments for Inpatient facility services/ Hospital services and stay and Physician inpatient and surgery services apply for inpatient services; or, if provided pro- vided on an outpatient basis, the outpatient facility services ser- vices and Outpatient Physician services payments applyap- ply. Inpatient facility services 10% Not covered Outpatient facility services 10Physician services 20% 25% 20% Not covered Physician services Benefits6 Your payment When using a Participating Provider3 10% CYD2 applies When using a Non-Participating Provider4 Not covered CYD2 applies Diagnostic x-ray, imaging, pathology, and laboratory services This payment is for Covered Services that are diagnosticdiagnos- tic, non-Preventive Health Services, and diagnostic radiological ra- diological procedures, such as CT scans, MRIs, MRAs, and PET scans. For the payments for Covered Services that are considered Preventive Health Services, see Preventive Health Services. Laboratory services Includes diagnostic Papanicolaou (Pap) test. Laboratory center 10% 30% 30% of up to $350/day Outpatient Department of a Hospital 10% plus 100% of additional charges X-ray and imaging services Includes diagnostic mammography. Outpatient radiology center 10% 30% 30% of up to $350/day Outpatient Department of a Hospital 10% plus 100% of additional charges Other outpatient diagnostic testing Testing to diagnose illness or injury such as vestibular vestibu- lar function tests, EKG, ECG, cardiac monitoring, non-invasive vascular studies, sleep medicine testingtest- ing, muscle and range of motion tests, EEG, and EMG. Office location 10% 30% 30% of up to $350/day Outpatient Department of a Hospital 10% plus 100% of additional charges Radiological and nuclear imaging services Outpatient radiology center 10% 30% 30% of up to $350/day Outpatient Department of a Hospital 10$35/visit $60/visit $35/visit $60/visit $35/visit $60/visit 20% 30% 40% 40% of up to $350/day plus 100% of addi- additional tional charges 40% 40% of up to $350/day plus 100% of addi- tional charges 40% 40% of up to $350/day plus 100% of addi- tional charges 40% 40% of up to $350/day plus 100% of addi- tional charges Rehabilitative and Habilitative Services Includes Physical Therapy, Occupational Therapy, Res- piratory Therapy, and Speech Therapy services. Office location $35/visit 40% Benefits6 Your payment When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Rehabilitative and Habilitative Services Includes physical therapy, occupational therapy, respiratory therapy, and speech therapy services. Office location 10% Outpatient Department of a Hospital 10% $35/visit 30% 3040% of up to $350/day plus 100% of additional addi- tional charges Durable medical equipment (DME) 3040% 30Not covered 40% 30% 3040% DME 10% Breast pump $0 Orthotic equipment and devices 10% Prosthetic equipment and devices 1020% $0 20% 20% Home health care services 10% Up to 100 visits per Member, per Calendar Year, by a home health care agency. All visits count towards the limit, including visits during any applicable Deductible period. Includes home visits by a nurse, Home Health Aide, medical social worker, physical therapist, speech therapist, or occupational therapist, and medical suppliessup- plies. 20% Not covered Home infusion and home injectable therapy services Home infusion agency services 10% Includes home infusion drugs and medical supplies. Home visits by an infusion nurse 10% Hemophilia home infusion services 10% Includes blood factor products. 20% 20% 20% Not covered Not covered Not covered Skilled Nursing Facility (SNF) services Up to 100 days per Member, per Benefit Period, except when provided as part of a Hospice program. All days count towards the limit, including days during any applicable ap- plicable Deductible period and days in different SNFs during the Calendar Year. Freestanding SNF 10% Hospital-based SNF 1020% 20% 5020% 3040% of up to $1,000600/day plus 100% of additional addi- tional charges When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Hospice program services Includes pre-Hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient inpa- tient respite care. $0 Not covered Other services and supplies Diabetes care services Devices, equipment, and supplies 20% 40% Benefits6 Your payment When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Self-management training $35/visit 40% Dialysis services 20% 40% of up to $350/day plus 100% of addi- tional charges PKU product formulas and Special Food Products 20% 20% Allergy serum billed separately from an office visit Hearing services Hearing aids and equipment 10% 10% 10% 10% 10% 20% 3040% 30Mental Health and Substance Use Disorder Benefits Your payment Mental health and substance use disorder Benefits are provided through Blue Shield's Mental Health Service Administrator (MHSA). When using a MHSA Participating Provider3 CYD2 applies When using a MHSA Non-Partic- ipating Provider4 CYD2 applies Outpatient services Office visit, including Physician office visit $35/visit 40% 30Other outpatient services, including intensive outpa- tient care, electroconvulsive therapy, transcranial magnetic stimulation, Behavioral Health Treatment for pervasive developmental disorder or autism in an 20% 40% office setting, home, or other non-institutional facility setting, and office-based opioid treatment 40% of up to Partial Hospitalization Program 20% $350/day plus 100% of addi- tional charges Psychological Testing 20% 40% Inpatient services Physician inpatient services $0 40% Hospital services 20% 40% of up to $350600/day plus 100% of additional addi- tional charges 10Residential Care 20% 40% of up to $600/day plus 100% of addi- tional charges 30% 20% Prior Authorization The following are some frequently-utilized Benefits that require prior authorization: Radiological and nuclear imaging services Hospice program services Outpatient mental health services, except office visits Inpatient facility services Please review the Evidence of Coverage for more about Benefits that require prior authorization. Notes
Appears in 1 contract
Samples: mrstaxbenefits.com
Emergency services Emergency room services. If admitted to the Hospital, this payment for emergency emer- gency room services does not apply. Instead, you pay the Participating Provider payment under Inpatient In- patient facility services/ Hospital services and stay. Emergency room Physician services 10$150/visit plus 20% 20% 10$150/visit plus 20% 10 20% 10% Benefits6 Your payment When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Urgent care center services 1020% 3050% Ambulance services This payment is for emergency or authorized transport. 1020% 1020% Outpatient facility services Ambulatory Surgery Center 10% 3050% of up to $350/day plus 100% of additional addi- tional charges Outpatient Department of a Hospital: surgery 1020% 3050% of up to $350/day plus 100% of additional addi- tional charges Outpatient Department of a Hospital: treatment of illness ill- ness or injury, radiation therapy, chemotherapy, and necessary supplies 1020% 3050% of up to $350/day plus 100% of additional addi- tional charges Inpatient facility services Hospital services and stay Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies. Special transplant facility inpatient services Physician inpatient services 1020% 1020% 1020% 3050% of up to $1,000600/day plus 100% of additional addi- tional charges Not covered Not covered Bariatric surgery services, designated California counties Not covered Not covered Not covered This payment is for bariatric surgery services for residents of designated California counties. For bariatric surgery services for residents of non- non-designated California counties, the payments for Inpatient facility services/ Hospital services and stay and Physician inpatient and surgery services apply for inpatient services; or, if provided pro- vided on an outpatient basis, the outpatient facility services ser- vices and Outpatient Physician services payments applyap- ply. Inpatient facility services 10% Not covered Outpatient facility services 10Physician services 20% 20% 20% Not covered Physician services Benefits6 Your payment When using a Participating Provider3 10% CYD2 applies When using a Non-Participating Provider4 Not covered CYD2 applies Diagnostic x-ray, imaging, pathology, and laboratory services This payment is for Covered Services that are diagnosticdiagnos- tic, non-Preventive Health Services, and diagnostic radiological ra- diological procedures, such as CT scans, MRIs, MRAs, and PET scans. For the payments for Covered Services that are considered Preventive Health Services, see Preventive Health Services. Laboratory services Includes diagnostic Papanicolaou (Pap) test. Laboratory center 1020% 30% 30% of up to $350/day Outpatient Department of a Hospital 1030% plus 100% of additional charges X-ray and imaging services Includes diagnostic mammography. Outpatient radiology center 1020% 30% 30% of up to $350/day Outpatient Department of a Hospital 1030% plus 100% of additional charges Other outpatient diagnostic testing Testing to diagnose illness or injury such as vestibular vestibu- lar function tests, EKG, ECG, cardiac monitoring, non-invasive vascular studies, sleep medicine testingtest- ing, muscle and range of motion tests, EEG, and EMG. Office location 1020% 30% 30% of up to $350/day Outpatient Department of a Hospital 1030% plus 100% of additional charges Radiological and nuclear imaging services Outpatient radiology center 1020% 30% 30% of up to $350/day Outpatient Department of a Hospital 10$100/visit plus 20% 50% 50% of up to $350/day plus 100% of addi- additional tional charges 50% 50% of up to $350/day plus 100% of addi- tional charges 50% 50% of up to $350/day plus 100% of addi- tional charges 50% 50% of up to $350/day plus 100% of addi- tional charges Rehabilitative and Habilitative Services Includes Physical Therapy, Occupational Therapy, Res- piratory Therapy, and Speech Therapy services. Office location 20% 50% Benefits6 Your payment When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Rehabilitative and Habilitative Services Includes physical therapy, occupational therapy, respiratory therapy, and speech therapy services. Office location 10% Outpatient Department of a Hospital 1020% 30% 3050% of up to $350/day plus 100% of additional addi- tional charges Durable medical equipment (DME) 3050% 30Not covered 50% 30% 3050% DME 10% Breast pump $0 Orthotic equipment and devices 10% Prosthetic equipment and devices 1020% $0 20% 20% Home health care services 10% Up to 100 visits per Member, per Calendar Year, by a home health care agency. All visits count towards the limit, including visits during any applicable Deductible period. Includes home visits by a nurse, Home Health Aide, medical social worker, physical therapist, speech therapist, or occupational therapist, and medical suppliessup- plies. 20% Not covered Home infusion and home injectable therapy services Home infusion agency services 10% Includes home infusion drugs and medical supplies. Home visits by an infusion nurse 10% Hemophilia home infusion services 10% Includes blood factor products. 20% 20% 20% Not covered Not covered Not covered Skilled Nursing Facility (SNF) services Up to 100 days per Member, per Benefit Period, except when provided as part of a Hospice program. All days count towards the limit, including days during any applicable ap- plicable Deductible period and days in different SNFs during the Calendar Year. Freestanding SNF 10% Hospital-based SNF 1020% 20% 5020% 3050% of up to $1,000600/day plus 100% of additional addi- tional charges When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Hospice program services Includes pre-Hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient inpa- tient respite care. $0 Not covered Other services and supplies Diabetes care services Devices, equipment, and supplies 20% 50% Benefits6 Your payment When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Self-management training 20% 50% Dialysis services 20% 50% of up to $350/day plus 100% of addi- tional charges PKU product formulas and Special Food Products 20% 20% Allergy serum billed separately from an office visit Hearing services Hearing aids and equipment 10% 10% 10% 10% 10% 20% 3050% 30Mental Health and Substance Use Disorder Benefits Your payment Mental health and substance use disorder Benefits are provided through Blue Shield's Mental Health Service Administrator (MHSA). When using a MHSA Participating Provider3 CYD2 applies When using a MHSA Non-Partic- ipating Provider4 CYD2 applies Outpatient services Office visit, including Physician office visit 20% 3050% Other outpatient services, including intensive outpa- tient care, electroconvulsive therapy, transcranial magnetic stimulation, Behavioral Health Treatment for pervasive developmental disorder or autism in an 20% 50% office setting, home, or other non-institutional facility setting, and office-based opioid treatment 50% of up to Partial Hospitalization Program 20% $350/day plus 100% of addi- tional charges Psychological Testing 20% 50% Inpatient services Physician inpatient services $0 50% Hospital services 20% 50% of up to $350600/day plus 100% of additional addi- tional charges 10Residential Care 20% 50% of up to $600/day plus 100% of addi- tional charges Prescription Drug Benefits8,9 Your payment When using a Participating Pharmacy3 CYD2 applies When using a Non-Participating Pharmacy4 CYD2 applies Retail pharmacy prescription Drugs Per prescription, up to a 30-day supply. Contraceptive Drugs and devices Tier 1 Drugs Tier 2 Drugs Tier 3 Drugs Tier 4 Drugs (excluding Specialty Drugs) $0 $10/prescription $25/prescription $40/prescription 30% up to $200/prescription Applicable Tier 1, Tier 2, or Tier 3 Co- payment 25% plus $10/prescription 25% plus $25/prescription 25% plus $40/prescription 30% up to $200/prescription plus 25% of pur- chase price Mail service pharmacy prescription Drugs Per prescription, up to a 90-day supply. Contraceptive Drugs and devices Tier 1 Drugs Tier 2 Drugs Tier 3 Drugs Tier 4 Drugs (excluding Specialty Drugs) $0 $20/prescription $50/prescription $80/prescription 30% up to $400/prescription Not covered Not covered Not covered Not covered Not covered Network Specialty Pharmacy Drugs Per prescription, up to a 30-day supply. Tier 4 Specialty Drugs 30% up to $200/prescription Not covered Oral Anticancer Drugs Per prescription, up to a 30-day supply. 30% up to $200/prescription Not covered Prior Authorization The following are some frequently-utilized Benefits that require prior authorization: Radiological and nuclear imaging services Hospice program services Outpatient mental health services, except office visits Inpatient facility services Some prescription Drugs (see xxxxxxxxxxxx.xxx/xxxxxxxx) Please review the Evidence of Coverage for more about Benefits that require prior authorization. Notes
Appears in 1 contract
Samples: myihopbenefits.com
Emergency services Emergency room services. If admitted to the Hospital, this payment for emergency room services does not apply. Instead, you pay the Participating Provider payment under Inpatient facility services/ Hospital services and stay. Emergency room Physician services 10$100/visit 20% 10% 10% 10$100/visit 20% When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Urgent care center services 1020% 3020% Ambulance services This payment is for emergency or authorized transport. 1020% 1020% Outpatient facility services Ambulatory Surgery Center 1020% 3020% of up to $350/day plus 100% of additional charges Outpatient Department of a Hospital: surgery 1020% 3020% of up to $350/day plus 100% of additional charges Outpatient Department of a Hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies 1020% 3020% of up to $350/day plus 100% of additional charges Inpatient facility services Hospital services and stay Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies. Special transplant facility inpatient services Physician inpatient services 1020% 1020% 1020% 3020% of up to $1,000600/day plus 100% of additional charges Not covered Not covered Bariatric surgery services, designated California counties This payment is for bariatric surgery services for residents of designated California counties. For bariatric surgery services for residents of non- designated California counties, the payments for Inpatient facility services/ Hospital services and stay and Physician inpatient and surgery services apply for inpatient services; or, if provided on an outpatient basis, the outpatient facility services and Outpatient Physician services payments apply. Inpatient facility services 1020% Not covered Outpatient facility services 1020% Not covered Physician services When using a Participating Provider3 1020% CYD2 applies When using a Non-Participating Provider4 Not covered CYD2 applies Diagnostic x-ray, imaging, pathology, and laboratory services This payment is for Covered Services that are diagnostic, non-Preventive Health Services, and diagnostic radiological procedures, such as CT scans, MRIs, MRAs, and PET scans. For the payments for Covered Services that are considered Preventive Health Services, see Preventive Health Services. Laboratory services Includes diagnostic Papanicolaou (Pap) test. Laboratory center 1020% 3020% 3020% of up to $350/day Outpatient Department of a Hospital 1020% plus 100% of additional charges X-ray and imaging services Includes diagnostic mammography. Outpatient radiology center 1020% 3020% 3020% of up to $350/day Outpatient Department of a Hospital 1020% plus 100% of additional charges Other outpatient diagnostic testing Testing to diagnose illness or injury such as vestibular function tests, EKG, ECG, cardiac monitoring, non-invasive vascular studies, sleep medicine testing, muscle and range of motion tests, EEG, and EMG. Office location 1020% 3020% 3020% of up to $350/day Outpatient Department of a Hospital 1020% plus 100% of additional charges Radiological and nuclear imaging services Outpatient radiology center 1020% 3020% 3020% of up to $350/day Outpatient Department of a Hospital 1020% plus 100% of additional charges When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Rehabilitative and Habilitative Services Includes physical therapy, occupational therapy, respiratory therapy, and speech therapy services. Office location 1020% Outpatient Department of a Hospital 1020% 20% 30% 3020% of up to $350/day plus 100% of additional charges Durable medical equipment (DME) 3020% 30Not covered 20% 30% 3020% DME 1020% Breast pump $0 Orthotic equipment and devices 1020% Prosthetic equipment and devices 1020% Home health care services 1020% Up to 100 visits per Member, per Calendar Year, by a home health care agency. All visits count towards the limit, including visits during any applicable Deductible period. Includes home visits by a nurse, Home Health Aide, medical social worker, physical therapist, speech therapist, or occupational therapist, and medical supplies. Not covered Home infusion and home injectable therapy services Home infusion agency services 1020% Includes home infusion drugs and medical supplies. Home visits by an infusion nurse 1020% Hemophilia home infusion services 1020% Includes blood factor products. Not covered Not covered Not covered Skilled Nursing Facility (SNF) services Up to 100 days per Member, per Benefit Period, except when provided as part of a Hospice program. All days count towards the limit, including days during any applicable Deductible period and days in different SNFs during the Calendar Year. Freestanding SNF 1020% Hospital-based SNF 1020% 5020% 3020% of up to $1,000600/day plus 100% of additional charges When using a Participating Provider3 CYD2 applies When using a Non-Participating Provider4 CYD2 applies Hospice program services Includes pre-Hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care. $0 Not covered Other services and supplies Diabetes care services Devices, equipment, and supplies Self-management training Dialysis services PKU product formulas and Special Food Products Allergy serum billed separately from an office visit Hearing services Hearing aids and equipment 1020% 1020% 1020% 10% 1020% 20% 3020% 3020% 3020% of up to $350/day plus 100% of additional charges 10% 3020% 20%
Appears in 1 contract
Samples: www.valleywater.org
