Radiation Therapy/Chemotherapy Services. This plan covers chemotherapy and radiation services. Respiratory Therapy This plan covers respiratory therapy services. When respiratory services are provided in your home, as part of a home care program, durable medical equipment, supplies, and oxygen are covered as a durable medical equipment service.
Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Tests, Labs, Imaging and X-rays - Diagnostic Outpatient, in a physician’s office, urgent care center or free-standing laboratory: Major diagnostic imaging and testing* including but not limited to: MRI, MRA, CAT scans, CTA scans, PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 40% - After deductible Sleep studies.* 0% - After deductible 40% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. 0% - After deductible 40% - After deductible Lab and pathology services. 0% - After deductible 40% - After deductible Diagnostic colorectal services - (Including, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 40% - After deductible Lyme disease diagnosis and treatment 0% - After deductible 40% - After deductible
Radiation Therapy/Chemotherapy Services. Medically necessary high dose chemotherapy and radiation services related to autologous bone marrow transplantation is limited. See definition of Experimental/investigational - Section 3.11.
Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Respiratory Therapy Inpatient 0% - After deductible 40% - After deductible Outpatient 0% - After deductible 40% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 40% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 40% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 40% - After deductible In a physician’s office 0% - After deductible 40% - After deductible Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay
Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 0% - After deductible Not Covered Surgery Services* Inpatient physician services 0% - After deductible Not Covered Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Telemedicine Services When rendered by our designated telemedicine provider. 0% - After deductible Not Covered When rendered by a network provider or non-network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered
Radiation Therapy/Chemotherapy Services. If you are dispensed a specialty prescription drug from a Rhode Island network provider, the charge for the specialty prescription drug is not reimbursed and the Rhode Island network provider may not seek reimbursement from you. If you are dispensed a specialty prescription drug from a non-network provider or by a provider that participates with an out of state Blue Cross and Blue Shield plan, the charge for the specialty prescription drug is not reimbursed. You are liable to pay the for the specialty prescription drug. Prescription drugs are reimbursed based on the type of service and the site of service. See the Summary of Pharmacy Benefits for benefit limits and the amount that you pay.
Radiation Therapy/Chemotherapy Services. Outpatient 0% - After Deductible 20% - After Deductible In a doctor’s office 0% - After Deductible 20% - After Deductible Respiratory Therapy Inpatient 0% - After Deductible 20% - After Deductible Outpatient 0% - After Deductible 20% - After Deductible Skilled Nursing Facility Care Skilled or sub-acute care* 0% - After Deductible 20% - After Deductible
Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Respiratory Therapy Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible Not Covered Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. $45 Not Covered Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Surgery Services* Physician services - includes physician services received inpatient, outpatient hospital, ambulatory surgical center facility, or physician’s office. 0% Not Covered Outpatient facility services – includes services received at an outpatient hospital or ambulatory surgical center facility. Standard $1,000 - After deductible Not Covered Enhanced $500 Not Covered Telemedicine Services When rendered by our designated telemedicine provider. $20 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay Not Covered
Radiation Therapy/Chemotherapy Services. If you are dispensed a specialty prescription drug from a Rhode Island network provider, the charge for the specialty prescription drug is not reimbursed and the Rhode Island network provider may not seek reimbursement from you. If you are dispensed a specialty prescription drug from a non-network provider or by a provider that participates with an out of state Blue Cross and Blue Shield plan, the charge for the specialty prescription drug is not reimbursed. You are liable to pay the for the specialty prescription drug. Prescription drugs are reimbursed based on the type of service and the site of service. See the Summary of Pharmacy Benefits for benefit limits and the amount that you pay. Coverage for prescription drugs is subject to the pharmacy program. The pharmacy program’s formulary includes a five-tier copayment structure and requires prescription drug preauthorization for certain Prescription Drugs. It also includes dose optimization conditions. Each of these items is described in more detail below. Coverage is provided for prescription drugs bought at a pharmacy, per the terms, conditions, exclusions, and limitations of this agreement.
Radiation Therapy/Chemotherapy Services. Outpatient 0% - After deductible 20% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Respiratory Therapy Inpatient 0% - After deductible 20% - After deductible Outpatient 0% - After deductible 20% - After deductible Skilled Care in a Nursing Facility* Skilled or sub-acute care 0% - After deductible 20% - After deductible Speech Therapy Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 40% - After deductible Surgery Services* Inpatient physician services 0% - After deductible 20% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 20% - After deductible In a physician’s office $15 20% - After deductible Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Telemedicine Services When rendered by our designated telemedicine provider. $30 Not Covered When rendered by a network provider other than our designated telemedicine provider. See the covered healthcare service being provided for the amount you pay See the covered healthcare service being provided for the amount you pay
