Benefit Summary. Medical/Prescription Norton City Schools Blue Access® (PPO) Covered Benefits Network Non-Network Deductible (Single/Family) $1,100/$2,200*(see wellness) $1,400/$2,800* (see wellness) Out-of-Pocket Limit (Single/Family) $1,900/$3,800* (see wellness) $2,800/$5,600* (see wellness) Physician Home and Office Services (PCP/SCP) Primary Care Physician (PCP)/ Specialty Care Physician (SCP) Including Office Surgeries and allergy serum: allergy injections (PCP and SCP) allergy testing MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies, Non-maternity related Ultrasounds and pharmaceutical products $30/$40 $10 10% 10% 30% 30% 30% 30% Preventive Care Services Services include but are not limited to: Routine Exams, Mammograms, Pelvic Exams, Pap testing, PSA tests, Immunizations1, Annual diabetic eye exam, Vision and Hearing screenings Physician Home and Office Visits (PCP/SCP) Other Outpatient Services @ Hospital/Alternative Care Facility No copayment/coinsurance No copayment/coinsurance 30% 30% Emergency and Urgent Care Emergency Room Services facility/other covered services (copayment waived if admitted) Urgent Care Center Services MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies, Non-maternity related Ultrasounds and pharmaceutical products Allergy injections Allergy testing $150 $40 10% $10 10% $150 30% 30% 30% 30% Inpatient and Outpatient Professional Services Include but are not limited to: Medical Care visits (1 per day), Intensive Medical Care, Concurrent Care, Consultations, Surgery and administration of general anesthesia and Newborn exams 10% 30% Inpatient Facility Services (Network/Non-Network combined) Unlimited days except for: 60 days for physical medicine/rehab (limit includes Day Rehabilitation Therapy Services on an outpatient basis) 120 days for skilled nursing facility 10% 30% Covered Benefits Network Non-Network Outpatient Surgery Hospital/Alternative Care Facility Surgery and administration of general anesthesia 10% 30% Other Outpatient Services (Combined Network & Non- Network limits) including but not limited to: Non Surgical Outpatient Services for example: MRIs, C-Scans, Chemotherapy, Ultrasounds, and other diagnostic outpatient services. Home Care Services 90 visits (excludes IV Therapy) Durable Medical Equipment and Orthotics Prosthetic Devices Prosthetic Limbs Physical Medicine Therapy Day Rehabilitation programs Hospice Care Ambulance Services 10% 10% 10% 30% 10% 10% Outpatient Therapy Services (Combined Network & Non-Network limits) Physician Home and Office Visits (PCP/SCP) Other Outpatient Services @ Hospital/Alternative Care Facility Limits apply to: Cardiac Rehabilitation Unlimited Pulmonary Rehabilitation Unlimited Physical Therapy: 30 visits Occupational Therapy: 30 visits Manipulation Therapy: 30 visits Speech therapy: 30 visits $30/$40 10% 30% 30% Accidental Dental: unlimited Copayments/Coinsurance based on setting where covered services are received 30% Behavioral Health: Mental Illness and Substance Abuse2 Inpatient Facility Services Inpatient Professional Services Physician Home and Office Visits (PCP/SCP) Other Outpatient Services. Outpatient Facility @ Hospital/Alternative Care Facility, Outpatient Professional 10% 10% $30/$30 10% 30% 30% 30% 30% Human Organ and Tissue Transplants3 Acquisition and transplant procedures, harvest and storage. 10% 30% Covered Benefits Network Non-Network Prescription Drugs Network Tier structure equals 1/2/3 /4 Network Retail Pharmacies: (30-day supply) Anthem Rx Direct Mail Service: (90-day supply) $10/$25/$50/10% max $1500 $20/$50/$100 Out of Pocket Limit: None 50%, min $30 5 Not covered Medicare Rx - Wrap Specialty Medications must be obtained via our Specialty Pharmacy network in order to receive network level benefits.
Appears in 2 contracts
Samples: Negotiated Agreement, Negotiated Agreement
Benefit Summary. Medical/Prescription Norton City Schools Blue Access® (PPO) Covered Benefits Network Non-Network Deductible (Single/Family) $1,100/$2,200*(see wellness) $1,400/$2,800* (see wellness) Out-of-Pocket Limit (Single/Family) $1,900/$3,800* (see wellness) $2,800/$5,600* (see wellness) Physician Home and Office Services (PCP/SCP) Primary Care Physician (PCP)/ Specialty Care Physician (SCP) Including Office Surgeries and allergy serum: 🞈 allergy injections (PCP and SCP) 🞈 allergy testing 🞈 MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies, 🞈 Non-maternity related Ultrasounds and pharmaceutical products $30/$40 $10 10% 10% 30% 30% 30% 30% Preventive Care Services Services include but are not limited to: Routine Exams, Mammograms, Pelvic Exams, Pap testing, PSA tests, Immunizations1, Annual diabetic eye exam, Vision and Hearing screenings 🞈 Physician Home and Office Visits (PCP/SCP) 🞈 Other Outpatient Services @ Hospital/Alternative Care Facility No copayment/coinsurance No copayment/coinsurance 30% 30% Emergency and Urgent Care Emergency Room Services 🞈 facility/other covered services (copayment waived if admitted) Urgent Care Center Services 🞈 MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies, Non-maternity related Ultrasounds and pharmaceutical products 🞈 Allergy injections 🞈 Allergy testing $150 $40 10% $10 10% $150 30% 30% 30% 30% Inpatient and Outpatient Professional Services Include but are not limited to: 🞈 Medical Care visits (1 per day), Intensive Medical Care, Concurrent Care, Consultations, Surgery and administration of general anesthesia and Newborn exams 10% 30% Inpatient Facility Services (Network/Non-Network combined) Unlimited days except for: 🞈 60 days for physical medicine/rehab (limit includes Day Rehabilitation Therapy Services on an outpatient basis) 🞈 120 days for skilled nursing facility 10% 30% Covered Benefits Network Non-Network Outpatient Surgery Hospital/Alternative Care Facility 🞈 Surgery and administration of general anesthesia 10% 30% Other Outpatient Services (Combined Network & Non- Network limits) including but not limited to: 🞈 Non Surgical Outpatient Services for example: MRIs, C-Scans, Chemotherapy, Ultrasounds, and other diagnostic outpatient services. 🞈 Home Care Services 90 visits (excludes IV Therapy) 🞈 Durable Medical Equipment and Orthotics 🞈 Prosthetic Devices 🞈 Prosthetic Limbs 🞈 Physical Medicine Therapy Day Rehabilitation programs 🞈 Hospice Care 🞈 Ambulance Services 10% 10% 10% 30% 10% 10% Outpatient Therapy Services (Combined Network & Non-Network limits) 🞈 Physician Home and Office Visits (PCP/SCP) 🞈 Other Outpatient Services @ Hospital/Alternative Care Facility Limits apply to: 🞈 Cardiac Rehabilitation Unlimited 🞈 Pulmonary Rehabilitation Unlimited 🞈 Physical Therapy: 30 visits 🞈 Occupational Therapy: 30 visits 🞈 Manipulation Therapy: 30 visits 🞈 Speech therapy: 30 visits $30/$40 10% 30% 30% Accidental Dental: unlimited Copayments/Coinsurance based on setting where covered services are received 30% Behavioral Health: Mental Illness and Substance Abuse2 🞈 Inpatient Facility Services 🞈 Inpatient Professional Services 🞈 Physician Home and Office Visits (PCP/SCP) 🞈 Other Outpatient Services. Outpatient Facility @ Hospital/Alternative Care Facility, Outpatient Professional 10% 10% $30/$30 10% 30% 30% 30% 30% Human Organ and Tissue Transplants3 🞈 Acquisition and transplant procedures, harvest and storage. 10% 30% Covered Benefits Network Non-Network Prescription Drugs Network Tier structure equals 1/2/3 /4 🞈 Network Retail Pharmacies: (30-day supply) 🞈 Anthem Rx Direct Mail Service: (90-day supply) $10/$25/$50/10% max $1500 $20/$50/$100 Out of Pocket Limit: None 50%, min $30 5 Not covered Medicare Rx - Wrap Specialty Medications must be obtained via our Specialty Pharmacy network in order to receive network level benefits.
Appears in 2 contracts
Samples: Negotiated Agreement, Negotiated Agreement
Benefit Summary. Medical/Prescription Norton City Schools Blue Access® (PPO) Covered Benefits Network Non-Network Deductible (Single/Family) $1,100/$2,200*(see wellness) $1,400/$2,800* (see wellness) Out-of-Pocket Limit (Single/Family) $1,900/$3,800* (see wellness) $2,800/$5,600* (see wellness) Physician Home and Office Services (PCP/SCP) Primary Care Physician (PCP)/ Specialty Care Physician (SCP) Including Office Surgeries and allergy serum: 🞈 allergy injections (PCP and SCP) 🞈 allergy testing 🞈 MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies, 🞈 Non-maternity related Ultrasounds and pharmaceutical products $30/$40 $10 10% 10% 30% 30% 30% 30% Preventive Care Services Services include but are not limited to: Routine Exams, Mammograms, Pelvic Exams, Pap testing, PSA tests, Immunizations1, Annual diabetic eye exam, Vision and Hearing screenings 🞈 Physician Home and Office Visits (PCP/SCP) 🞈 Other Outpatient Services @ Hospital/Alternative Care Facility No copayment/coinsurance No copayment/coinsurance 30% 30% Emergency and Urgent Care Emergency Room Services 🞈 facility/other covered services (copayment waived if admitted) Urgent Care Center Services 🞈 MRAs, MRIs, PETS, C-Scans, Nuclear Cardiology Imaging Studies, Non-maternity related Ultrasounds and pharmaceutical products 🞈 Allergy injections 🞈 Allergy testing $150 $40 10% $10 10% $150 30% 30% 30% 30% Inpatient and Outpatient Professional Services Include but are not limited to: 🞈 Medical Care visits (1 per day), Intensive Medical Care, Concurrent Care, Consultations, Surgery and administration of general anesthesia and Newborn exams 10% 30% Inpatient Facility Services (Network/Non-Network combined) Unlimited days except for: 🞈 60 days for physical medicine/rehab (limit includes Day Rehabilitation Therapy Services on an outpatient basis) 🞈 120 days for skilled nursing facility 10% 30% Covered Benefits Network Non-Network Outpatient Surgery Hospital/Alternative Care Facility 🞈 Surgery and administration of general anesthesia 10% 30% Other Outpatient Services (Combined Network & Non- Network limits) including but not limited to: 🞈 Non Surgical Outpatient Services for example: MRIs, C-Scans, Chemotherapy, Ultrasounds, and other diagnostic outpatient services. 🞈 Home Care Services 90 visits (excludes IV Therapy) 🞈 Durable Medical Equipment and Orthotics 🞈 Prosthetic Devices 🞈 Prosthetic Limbs 🞈 Physical Medicine Therapy Day Rehabilitation programs 🞈 Hospice Care 🞈 Ambulance Services 10% 10% 10% 30% 10% 10% Outpatient Therapy Services (Combined Network & Non-Network limits) 🞈 Physician Home and Office Visits (PCP/SCP) 🞈 Other Outpatient Services @ Hospital/Alternative Care Facility Limits apply to: 🞈 Cardiac Rehabilitation Unlimited 🞈 Pulmonary Rehabilitation Unlimited 🞈 Physical Therapy: 30 visits 🞈 Occupational Therapy: 30 visits 🞈 Manipulation Therapy: 30 visits 🞈 Speech therapy: 30 visits $30/$40 10% 30% 30% Accidental Dental: unlimited Copayments/Coinsurance based on setting where covered services are received 30% Behavioral Health: Mental Illness and Substance Abuse2 🞈 Inpatient Facility Services 🞈 Inpatient Professional Services 🞈 Physician Home and Office Visits (PCP/SCP) 🞈 Other Outpatient Services. Outpatient Facility @ Hospital/Alternative Care Facility, Outpatient Professional 10% 10% $30/$30 10% 30% 30% 30% 30% Human Organ and Tissue Transplants3 🞈 Acquisition and transplant procedures, harvest and storage. 10% 30% Covered Benefits Network Non-Network Prescription Drugs Network Tier structure equals 1/2/3 /4 1/2/3/4 🞈 Network Retail Pharmacies: (30-day supply) 🞈 Anthem Rx Direct Mail Service: (90-day supply) $10/$25/$50/10% max $1500 $20/$50/$100 Out of Pocket Limit: None 50%, min $30 5 Not covered Medicare Rx - Wrap Specialty Medications must be obtained via our Specialty Pharmacy network in order to receive network level benefits.
Appears in 1 contract
Samples: serb.ohio.gov
