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. 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. (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Asthma management 0% 20% - After deductible 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 Optometrists and Ophthalmologists; Oral Surgery; 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 -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. 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. 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. (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Asthma management 0% Not Covered 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 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. 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. 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. Asthma management 0% Not Covered Hospital emergency room $150 The level of coverage is the same as network provider. Coverage varies based on type of service. Hearing exam $30 Not Covered Hearing diagnostic testing 0% Not Covered Hearing aids - The benefit limit is $2,000 per hearing aid for a member under 21, the benefit limit is $700 per hearing aid for a member 21 and older. 20% - After deductible The level of coverage is the same as network provider. Intermittent skilled services when billed by a home health care agency. 0% - After deductible Not Covered Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human leukocyte antigen testing 0% Not Covered Inpatient/outpatient/in a physician’s office. Three (3) in-vitro fertilization cycles will be covered per plan year with a total of eight (8) in-vitro fertilization cycles covered in a member’s lifetime. 20% - After deductible Not Covered
Hair Prosthetics. (Wigs)*; • Hearing Aids*; • Obstetricians and Gynecologists; • Oncologists - Office Visits (consultation or second opinion; all other services require a • 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 -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. 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. (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay 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. Asthma management 0% 20% - After deductible Hospital emergency room $100 The level of coverage is the same as network provider. Coverage varies based on type of service. Hearing exam $30 20% - After deductible Hearing diagnostic testing 0% 20% - After deductible Hearing aids - The benefit limit is $1,500 per hearing aid for a member under 19; the benefit limit is $700 per hearing aid for a member 19 and older. 20% - After deductible The level of coverage is the same as network provider. Intermittent skilled services when billed by a home health care agency. 0% - After deductible 20% - After deductible Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible 20% - After deductible Human leukocyte antigen testing 0% - After deductible 20% - After deductible
