Hair Prosthetics. Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.
Hair Prosthetics. Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.
Hair Prosthetics. Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Early Intervention Services (EIS) Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% The level of coverage is the same as network provider. 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 Education - Asthma Asthma management 0% 20% - After deductible Emergency Room Services Hospital emergency room $200 The level of coverage is the same as network provider.
Hair Prosthetics. Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Early Intervention Services (EIS) Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% The level of coverage is the same as network provider. 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 Education - Asthma Asthma management 0% Not Covered Emergency Room Services Hospital emergency room $200 The level of coverage is the same as network provider.
Hair Prosthetics. (Wigs)*; Hearing Aids*; Obstetricians and Gynecologists; Oncologists - Office Visits (consultation or second opinion; all other services require a referral); Optometrists and Ophthalmologists; Oral Surgery; Pediatric Dental Services; Pediatric Vision Services; Retail Clinics; and Telemedicine Services when rendered by a designated provider. * You may self-refer to a non-network provider for covered healthcare services for Early Intervention Services, Hair Prosthetics, and Hearing Aids. Deductible; Maximum Out-of-Pocket Expense Network Providers Non-network Providers You Pay You pay Deductible -The amount you must pay each plan year before we begin to pay for certain covered healthcare services. See Glossary section for further details. The deductible applies to network and non-network services separately. Services that apply the deductible are indicated as "After Deductible" in the Summary of Medical Benefits and the Summary of Pharmacy Benefits. Deductible for an Individual Plan: $2,000 $4,000 Deductible for a Family Plan: The Family plan deductible is met by adding the amount of covered healthcare expenses applied to the deductible for all family members; however no one (1) member can contribute more than the amount shown above for "Deductible for an Individual Plan". $4,000 $8,000 Maximum Out-of-Pocket Expense - The total combined amount of your deductible and copayments you must pay each plan year for certain covered healthcare services. See Glossary section for further details. The maximum out-of-pocket expense limit accumulates separately for network and non-network services. The deductible and copayments (including, but not limited to, office visits copayments and prescription drug copayments) apply to the maximum out-of-pocket expense. Maximum Out-of-Pocket Expense for an Individual Plan: $6,000 $12,000
Hair Prosthetics. (Wigs)*; Hearing Aids*; Obstetricians and Gynecologists; Oncologists - Office Visits (consultation or second opinion; all other services require a referral); Optometrists and Ophthalmologists; Oral Surgery; Retail Clinics; and Telemedicine Services when rendered by a designated provider.
Hair Prosthetics. Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 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 Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible Not Covered Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider.
Hair Prosthetics. (Wigs)*; • Hearing Aids*; • Obstetricians and Gynecologists; • Oncologists - Office Visits (consultation or second opinion; all other services require a referral); • Optometrists and Ophthalmologists; • Oral Surgery; • Pediatric Dental Services; • Pediatric Vision Services; • Retail Clinics; and • Telemedicine Services when rendered by a designated provider. * You may self-refer to a non-network provider for covered healthcare services for Early Intervention Services, Hair Prosthetics, and Hearing Aids. Deductible; Maximum Out-of-Pocket Expense Network Providers Non-network Providers You Pay You pay Deductible -The amount you must pay each plan year before we begin to pay for certain covered healthcare services. See Glossary section for further details. The deductible applies to network and non-network services separately. Services that apply the deductible are indicated as "After Deductible" in the Summary of Medical Benefits and the Summary of Pharmacy Benefits.
Hair Prosthetics. (Wigs)*; • Hearing Aids*; • Obstetricians and Gynecologists; • Oncologists - Office Visits (consultation or second opinion; all other services require a referral); • Optometrists and Ophthalmologists; • Oral Surgery; • PCPs other than your designated PCP; • Pediatric Dental Services; • Pediatric Vision Services; • Retail Clinics; • Speech Therapy; and • Telemedicine services when rendered by our designated telemedicine provider, PCPs, or applicable services provided by specialists identified on this self-referral list.
Hair Prosthetics. Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 20% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 20% - After deductible Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 20% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 20% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 20% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as care coordinated by your primary care physician and permitted self-referrals. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as care coordinated by your primary care physician and permitted self-referrals.
