Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply?
Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply? 40% for all other outpatient services including Intensive Behavioral Therapy, Transcranial Magnetic Stimulation, Electroconvulsive Therapy, and Psychological Testing Yes Yes $35 per visit Yes No Morbid Obesity surgery must be received from a Designated Provider. 40% Yes Yes Necessary Medical Supplies 40% Yes Yes Orthotics 40% Yes Yes Pharmaceutical Products which, due to their traits (as determined by us), are administered or directly supervised by a qualified provider or licensed/certified health professional. Note: Benefits for medication normally available by a prescription or order or refill are provided as described under your Outpatient Prescription Drug Section. 40% Yes Yes SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Amounts or, for specific Covered Health Care Services as described in the definition of Recognized Amount in the Policy, Recognized Amounts. The Allowed Amounts provision near the end of this Schedule of Benefits will tell you when you are responsible for amounts that exceed the Allowed Amount.
Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply? 40% Yes Yes Surgery - Outpatient 40% Yes Yes Telehealth Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. Temporomandibular Joint Syndrome (TMJ) 40% Yes Yes Therapeutic Treatments - Outpatient 40% Yes Yes Transplantation services must be received from a Designated Provider. Covered expenses for travel, lodging and food are limited to $10,000 per transplant. All claims filed for travel and lodging expenses must include detailed receipts, except for mileage. Mileage will be calculated based on the home address of the Covered Person and the transplant site. Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits. Benefits include the facility charge, supplies and all professional services required to treat your $75 per visit Yes No SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Amounts or, for specific Covered Health Care Services as described in the definition of Recognized Amount in the Policy, Recognized Amounts. The Allowed Amounts provision near the end of this Schedule of Benefits will tell you when you are responsible for amounts that exceed the Allowed Amount.
Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Dollar Amount or Percentage. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply? Allowed Amounts For Network Benefits, Allowed Amounts are based on the following: When Covered Health Care Services are received from an out-of-Network provider as described below, Allowed Amounts are determined as follows:
Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply? $75 per service at a Hospital-based lab Yes No $15 per service at a Physician office-based lab Yes No
Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply? $75 per service at a Hospital-based lab Yes No X-Ray and Other Diagnostic Testing - Outpatient 40% at a freestanding diagnostic center or in a Physician's office Yes Yes 50% at an outpatient Hospital-based diagnostic center Yes Yes Lymphedema Services Depending upon where the Covered Health Care Service is provided, Benefits will be the same as those stated under each Covered Health Care Service category in this Schedule of Benefits.
Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co-payment, Co- insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply? Care Service category in this Schedule of Benefits except that an Annual Deductible will not apply for a newborn child whose length of stay in the Hospital is the same as the mother's length of stay.
Covered Health Care Service. What Is the Co- payment or Co- insurance You Pay? This May Include a Co- payment, Co-insurance or Both. Does the Amount You Pay Apply to the Out-of-Pocket Limit? Does the Annual Deductible Apply? Vision Correction After Surgery or Injury Allowed Amounts For Network Benefits, Allowed Amounts are based on the following: When Covered Health Care Services are received from an out-of-Network provider as described below, Allowed Amounts are determined as follows:
