Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% Not Covered Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible Not Covered
Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 20% - After deductible
Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 40% - After deductible Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible 40% - 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 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 theamount you pay See the covered healthcare service being provided for the amount 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 colorec...
Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 40% - After deductible Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible 40% - After deductible
Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% 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 Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible Not Covered
Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% Not Covered Private Duty Nursing Services* Must be performed by a certified home health care agency. 0% - After deductible Not Covered 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. $15 - 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 See the covered healthcare service being provided for the amount you pay
Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% Not Covered Urgent Care Urgent care services $50 The level of coverage is the same as network provider.
Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. Preventive office visits Includes adult annual and pediatric office/clinic visits. 0% 20% plus $25 - After deductible Well woman annual visit 0% 20% plus $40 - After deductible Preventive counseling/education Includes diabetes education, nutritional counseling and smoking cessation counseling and genetic counseling for BRCA. 0% 20% plus $40 - After deductible Immunizations Includes adult, pediatric and travel immunizations. 0% 20% - After deductible Preventive Screenings 0% 20% - After deductible Preventive High End Radiology 0% 20% - After deductible Contraceptive and Sterilization services for women 0% 20% - After deductible Breast pumps 0% 20% - After deductible
Prevention Care Services and Early Detection Services. Preventive office visits Includes adult annual and pediatric office/clinic visits. 0% 20% plus $15 - After deductible Well woman annual visit 0% 20% plus $25 - After deductible Preventive counseling/education Includes diabetes education, nutritional counseling and smoking cessation counseling and genetic counseling for BRCA. 0% 20% plus $25 - After deductible Immunizations Includes adult, pediatric and travel immunizations. 0% 20% - After deductible Preventive Screenings 0% 20% - After deductible Contraceptive services for women 0% 20% - After deductible** Sterilization services for women 0% 20% - After deductible Breast pumps 0% 20% - After deductible**
Prevention Care Services and Early Detection Services. See Prevention and Early Detection Services section for details. 0% Not Covered
