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
Appears in 1 contract
Samples: Subscriber Agreement
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 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. 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 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 $150 200 The level of coverage is the same as network provider. Coverage varies based on type of service. Hearing exam $30 45 Not Covered Hearing diagnostic testing 020% - After deductible Not Covered Hearing aids - The benefit limit is $2,000 1,500 per hearing aid for a member under 21, 19; the benefit limit is $700 per hearing aid for a member 21 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. 020% - After deductible Not Covered Inpatient/in your home. When provided by an approved hospice care program. 020% - After deductible Not Covered Human leukocyte antigen testing 020% - After deductible 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
Appears in 1 contract
Samples: Subscriber Agreement
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% - 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 Asthma management 0% - After deductible Not Covered Hospital emergency room $150 The level of coverage is the same as network provider. 0% - After deductible Not Covered Coverage varies based on type of service. Hearing exam $30 0% - After deductible Not Covered Hearing diagnostic testing 0% - After deductible 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% - After deductible 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. 200% - After deductible Not Covered Outpatient - facility 0% - After deductible Not Covered In the physician’s office/in your home 0% - After deductible Not Covered General hospital or specialty hospital services* - Unlimited Days 0% - After deductible Not Covered Rehabilitation facility services* - Limited to 45 days per plan year. 0% - After deductible Not Covered Physician hospital visits 0% - After deductible Not Covered Inpatient - see Mastectomy Services in Section 3 for details. 0% - After deductible Not Covered Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% - After deductible Not Covered Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% - After deductible Not Covered
Appears in 1 contract
Samples: Subscriber Agreement
Hair Prosthetics. Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 200% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 200% - 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. 200% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 200% - After deductible Not Covered Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 200% - After deductible Not Covered Enteral formula or food taken orally * 200% - 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. 200% - 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% - 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 Asthma management 0% - After deductible Not Covered Hospital emergency room $150 The level of coverage is the same as network provider. 0% - After deductible Not Covered Coverage varies based on type of service. Hearing exam $30 0% - After deductible Not Covered Hearing diagnostic testing 0% - After deductible 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. 200% - 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% - After deductible 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. 200% - After deductible Not Covered Outpatient - facility 0% - After deductible Not Covered In the physician’s office/in your home 0% - After deductible Not Covered General hospital or specialty hospital services* - Unlimited Days 0% - After deductible Not Covered Rehabilitation facility services* - Limited to 45 days per plan year. 0% - After deductible Not Covered Physician hospital visits 0% - After deductible Not Covered Inpatient - see Mastectomy Services in Section 3 for details. 0% - After deductible Not Covered Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% - After deductible Not Covered Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% - After deductible Not Covered
Appears in 1 contract
Samples: Subscriber Agreement
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% $25 Not Covered Hospital emergency room $150 100 The level of coverage is the same as network provider. Coverage varies based on type of service. Hearing exam $30 25 Not Covered Hearing diagnostic testing 0% Not Covered Hearing aids - The benefit limit is $2,000 1,500 per hearing aid for a member under 21, 19; the benefit limit is $700 per hearing aid for a member 21 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 Not Covered Inpatient/in your home. When provided by an approved hospice care program. 0% - After deductible Not Covered Human leukocyte antigen testing 0% - After deductible Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay 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 CoveredCovered Outpatient - facility 0% - After deductible Not Covered In the physician’s office/in your home 0% - After deductible Not Covered General hospital or specialty hospital services* - Unlimited Days 0% - After deductible Not Covered Rehabilitation facility services* - Limited to 45 days per plan year. 0% - After deductible Not Covered Physician hospital visits 0% - After deductible Not Covered Inpatient - see Mastectomy Services in Section 3 for details. 0% Not Covered Surgery services - includes mastectomy and reconstructive surgery. See Mastectomy Services in Section 3 for details. 0% Not Covered Mastectomy-related treatment - includes prostheses and treatment for physical complications. 0% Not Covered In a hospital or other health care facility 0% - After deductible Not Covered Office Visits - (Other than Preventive Care Services. See Prevention and Early Detection Services for coverage of annual preventive officevisits.) Allergy injections - Applies to injection only, including administration. 0% Not Covered Hospital based clinic visits $25 Not Covered Pediatric clinic visit $10 Not Covered PCP visits - including behavioral health. Visits include PCP office visits and PCP house calls. $10 Not Covered Retail clinics $10 Not Covered Specialists Office visits and house calls rendered by a specialist (other than a behavioral health specialist). Specialist includes but is not limited to allergists, dermatologists and podiatrists. $25 Not Covered Office visits and house calls rendered by a behavioral health specialist. $10 Not Covered Organ transplant services 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered Pre-natal, delivery, and postpartum services. 0% - After deductible Not Covered (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Prescription drugs and diabetic equipmentand supplies purchased at a retail, specialty, or mail order pharmacy. See Summary of PharmacyBenefits See Summary of Pharmacy Benefits Prescription drugs requiringadministration by a licensed health care provider*: Prescription drugs other than infused drugs - includes but is not limited to: medications by injection or inhalation, as well as nasal, topical, or transdermal medications. 0% - After deductible Not Covered Infused drugs 0% - After deductible Not Covered See Prevention and Early Detection Services section for details. 0% Not Covered Must be performed by a certified home health care agency. 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered In a physician’s office 0% - After deductible Not Covered Inpatient 0% - After deductible Not Covered Outpatient 0% - After deductible Not Covered Skilled or sub-acute care 0% - After deductible Not Covered Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible Not Covered 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 When rendered by our designated telemedicine provider. $10 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 theamount you pay See the covered healthcare service being provided for the amount you pay
Appears in 1 contract
Samples: Subscriber Agreement
