Pregnancy and Maternity Services. Pre-natal, delivery, and postpartum services. 0% - After deductible 20% - After deductible Prescription drugs and diabetic equipment and supplies purchased at a retail, specialty, or mail order pharmacy. See Summary of PharmacyBenefits See Summary of PharmacyBenefits Prescription drugs requiring administration 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 20% - After deductible Infused drugs 0% - After deductible 20% - 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 or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay See Prevention and Early Detection Services section for details. 0% 20% - After deductible Must be performed by a certified home health care agency. 0% - After deductible 20% - After deductible Outpatient 0% - After deductible 20% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Inpatient 0% - After deductible 20% - After deductible Outpatient 0% - After deductible 20% - After deductible Skilled or sub-acute care 0% - After deductible 20% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 40% - After deductible Inpatient physician services 0% - After deductible 20% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 20% - After deductible In a physician’s office. 0% 20% - After deductible When rendered by our designated telemedicine provider. $20 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 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 20% - After deductible Sleep studies.* 0% - After deductible 20% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. $50 20% - After deductible Lab and pathology services. $20 20% - 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 colorectal services.) 0% - After deductible 20% - After deductible Lyme disease diagnosis and treatment $20 20% - After deductible Urgent care services $75 The level of coverage is the same as network provider. Vision exam - one routine eye exam per member per plan year. $0 20% - After deductible Non-routine eye exam $0 20% - After deductible The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty. For information about our pharmacy network, visit our website or call our Customer Service Department.
Appears in 1 contract
Samples: Subscriber Agreement
Pregnancy and Maternity Services. Pre-natal, delivery, and postpartum services. 0% - After deductible 20% - After deductible Prescription drugs and diabetic equipment and supplies purchased at a retail, specialty, or mail order pharmacy. See Summary of PharmacyBenefits See Summary of PharmacyBenefits Prescription drugs requiring administration 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 20% - After deductible Infused drugs 0% - After deductible 20% - After deductible 20%- Afterdeductible Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers NetworkProviders Non-network Providers (*) Preauthorization may be required for this service or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Prescription Drugs and Diabetic Equipment and Supplies Prescription drugs and diabetic equipment and supplies dispensed at a pharmacy. See Summary of Pharmacy Benefits for prescription drugs purchased at a retail, specialty, or mail ordperharmacy. Prescription drugs dispensed and administered by a licensed health careprovider(other than a pharmacist), and notpurchased from a retail, specialty or mail order pharmacy: Injectable drug*s 20% 20%- Afterdeductible Infused drug*s 20% 20%- Afterdeductible Medications other than injected and infused d*rugs Are included in the allowanc for the medical service bein rendered. Are included in the allowanc for the medical service being rendered. See Prevention and Early Detection Services section for fo details. 0% 20% - After deductible 20%- Afterdeductible Private Duty Nursing Service*s Must be performed by a certified home health care agency. age 0% - After deductible 20% - After deductible 20%- Afterdeductible Radiation Therapy/Chemotherapy Services Outpatient 0% - After deductible 20% - After deductible 20%- Afterdeductible In a physician’s office S K o\ ffiVce L F L D Q ¶ V 0% - After deductible 20% - After deductible 20%- Afterdeductible Inpatient 0% - After deductible 20% - After deductible 20%- Afterdeductible Outpatient 0% - After deductible 20% - After deductible 20%- Afterdeductible Skilled or subsu-acute bacute care 0% - After deductible 20% - After deductible 20%- Afterdeductible Outpatient hospital/in hospitainl/ a physician’s/therapist’s officeS K \ WV KL XX XX DD Limited to30 speech therapy visits peprlan year. 20% - After deductible 40% - After deductible 20%- Afterdeductible Inpatient physician services physiciasnervices 0% 20%- Afterdeductible Outpatientservices - After deductible 20% - After deductible Outpatient services - includes physician services includesphysicianservices and outpatient hospital or hospitaolr ambulatory surgical center facility centfearcility services. 0% - After deductible 20% - After deductible 20%- Afterdeductible In a physician’s officeS K o\ ffiVce. L F L D Q ¶ V 0% 20% - After deductible 20%- Afterdeductible Telemedicine Services When rendered by our designated telemedicine providera designatepdrovider. $20 15 Not Covered When rendered by anetworkprovider. $15 Not Covered Outpatien,tin 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 OutpatientS K o\ ffiVce, in a physician’s office, urgent care center or uLrgenFt caLreceDnterQor ¶ free-standing laboratory: Major diagnostic imaging and testing* including tes*tiinngcluding but not limited to: MRI, MRA, CAT scans, CTA scans, scans PET scans, nuclear medicine and cardiac imaging. 0% - After deductible 20% - After deductible 20%- Afterdeductible Sleep studies.* *. 0% - After deductible 20% - After deductible 20%- Afterdeductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. $50 20abov 0% - After deductible 20%- Afterdeductible Lab and pathology services. $20 200% - After deductible 20%- Afterdeductible Covered Benefits- See Covered Healthcare Services for additional benefit limits and details. NetworkProviders Non-network Providers (*) Preauthorization may be required for this service or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay Diagnostic colorectal services - (Includingservic-e(sIncluding, but not limited to, fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and barium enema. See S Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 20% - After deductible 20%- Afterdeductible Lyme disease diagnosis and treatment $20 200% - After deductible 20%- Afterdeductible Urgent care services $75 15 The level of coverage is the same as network provider. xxxxxx.xx Vision exam - Care Services Vision exam- one routine eye exam per member per pemr emberper plan year. $0 20% - After deductible 15 20%- Afterdeductible Non-routine eye routineeye exam $0 20% - After deductible 15 20%- Afterdeductible SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty. For information about our pharmacy network, visit our website or call our Customer Service Department.
Appears in 1 contract
Samples: Subscriber Agreement
Pregnancy and Maternity Services. Pre-natal, delivery, and postpartum services. 0% - After deductible 20% - After deductible Prescription drugs and diabetic equipment and supplies purchased at a retail, specialty, or mail order pharmacy. See Summary of PharmacyBenefits See Summary of PharmacyBenefits Prescription drugs requiring administration 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 20% - After deductible Infused drugs 0% - After deductible 20% - 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 or for certain services in the benefit category. Please see Preauthorization in Section 5 for more information. You Pay You Pay See Prevention and Early Detection Services section for details. 0% 20% - After deductible Must be performed by a certified home health care agency. 0% - After deductible 20% - After deductible Outpatient 0% - After deductible 20% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Inpatient Outpatient 0% - After deductible 20% - After deductible Outpatient In a physician’s office 0% - After deductible 20% - After deductible Skilled or sub-acute care 0% - After deductible 20% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 40% - After deductible Inpatient physician services 0% - After deductible 20% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 20% - After deductible In a physician’s office. office 0% 20% - After deductible When rendered by our designated telemedicine provider. $20 30 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 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 20% - After deductible Sleep studies.* 0% - After deductible 20% - After deductible Diagnostic imaging and tests, other than major diagnostic imaging and testing services noted above. $50 20% - After deductible Lab and pathology services. $20 20% - 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 colorectal services.) 0% - After deductible 20% - After deductible Lyme disease diagnosis and treatment $20 20% - After deductible Urgent care services $75 The level of coverage is the same as network provider. Vision exam - one routine eye exam per member per plan year. $0 20% - After deductible Non-routine eye exam $0 20% - After deductible The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty. For information about our pharmacy network, visit our website or call our Customer Service Department.pay
Appears in 1 contract
Samples: Subscriber Agreement
Pregnancy and Maternity Services. Pre-natal, delivery, and deliverya,nd postpartum services. 0% - After deductible 20% - After deductible 0%- Afterdeductible 20%- Afterdeductible Prescription Drugs and Diabetic Equipment and Supplies Prescription drugs and diabetic equipment and supplies dispensed at a pharmacy. See Summary of Pharmacy Benefits for prescription drugs purchased at a retail, specialty, or mail order pharmacyordperharmacy. See Summary of PharmacyBenefits See Summary of PharmacyBenefits Prescription drugs requiring administration dispensed and administered by a licensed health care provider*careprovider(other than a pharmacist), an notpurchased from a retail, specialty or mail order pharmacy: Prescription drugs Injectable drugs* 0%- Afterdeductible 20%- Afterdeductible Infused drugs* 0%- Afterdeductible 20%- Afterdeductible Medications other than injected and infused drugs - includes but is not limited to: medications by injection or inhalation, as well as nasal, topical, or transdermal medicationsrugs* Are included in thaellowance for the medical service bein rendered. 0% - After deductible 20% - After deductible Infused drugs 0% - After deductible 20% - After deductible Are included in thaellowance for the medical service being rendered. Covered Benefits - Benefits- See Covered Healthcare Services for additional benefit limits and details. Network Providers NetworkProviders Non-network Providers (*) Preauthorization may be required for this service or for certain services in the benefit categoryservice. Please see Preauthorization in Section 5 for more information. You Pay You Pay Prevention Care Services and Early Detection Services See Prevention and Early Detection Services section for details. 0% 20% - After deductible 20%- Afterdeductible Must be performed by a certified home health care agency. agen 0%- Afterdeductible 20%- Afterdeductible Radiation Therapy/Chemotherapy Services Outpatient 0%- Afterdeductible 20%- Afterdeductible In a S K o\ ffiVce L F L D Q ¶ V 0%- Afterdeductible 20%- Afterdeductible Inpatient 0%- Afterdeductible 20%- Afterdeductible Outpatient 0%- Afterdeductible 20%- Afterdeductible Skilled Care in a Nursing Facility* Skilled or su-bacute care 0%- Afterdeductible 20%- Afterdeductible Outpatient hospitainl/ a S K \ WV KL XX XX DD 20%- Afterdeductible 40%- Afterdeductible Inpatient physiciasnervices 0%- Afterdeductible 20%- Afterdeductible Outpatient physiciasnervices 0%- Afterdeductible 20%- Afterdeductible In a S K o\ ffiVce L F L D Q ¶ V 0% - After deductible 20% - After deductible Outpatient 0% - After deductible 20% - After deductible In a physician’s office 0% - After deductible 20% - After deductible Inpatient 0% - After deductible 20% - After deductible Outpatient 0% - After deductible 20% - After deductible Skilled or sub-acute care 0% - After deductible 20% - After deductible Outpatient hospital/in a physician’s/therapist’s office. 20% - After deductible 40% - After deductible Inpatient physician services 0% - After deductible 20% - After deductible Outpatient services - includes physician services and outpatient hospital or ambulatory surgical center facility services. 0% - After deductible 20% - After deductible In a physician’s office. 0% 20% - After deductible 20%- Afterdeductible Telemedicine Services When rendered by our designated telemedicine providera designatepdrovider. $20 25 Not Covered When rendered by anetworkprovider. $25 Not Covered Outpatien,tin 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 OutpatientS K o\ ffiVce, in a physician’s office, urgent care center or uLrgenFt caLreceDnterQor ¶ 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 imagingmedicine*. 0% - After deductible 20% - After deductible 0%- Afterdeductible 20%- Afterdeductible Sleep studies.* 0% - After deductible 20% - After deductible 0%- Afterdeductible 20%- Afterdeductible Diagnostic imaging and tests, other than major diagnostic the diagnosti imaging and testing services noted listed above. $50 20% - After deductible 75 20%- Afterdeductible Lab and pathology services. $20 20% - After deductible 25 20%- Afterdeductible Diagnostic colorectal services - (Includingservic-e(sIncluding, but not limited limite to, fecal occult blood testingblodotesting, flexible sigmoidoscopy, colonoscopy, and barium enema. See Prevention and Early Detection Services for preventive colorectal services.) 0% - After deductible 20% - After deductible 0%- Afterdeductible 20%- Afterdeductible Lyme disease diagnosis and treatment $20 20% - After deductible 25 20%- Afterdeductibel Urgent care services $75 100 The level of coverage is the same as network provider. xxxxxx.xx Vision exam - Care Services Vision exam- one routine eye exam per member per pemr emberper plan year. $0 20% - After deductible 20%- Afterdeductible Non-routine eye exam $0 2020%- Afterdeductible Pediatric vision care fomrembersunder age 19: See Vision Services in Section 3 fobrenefitlimitsand details. These services only apply to an enrollmedemberunder the age of 19:. Prescription glasses- frame and lenses 0% - After deductible Not Covered Contact lens (in lieu of prescription glasses) 0% Not Covered Vision hardware for enrollmedembersaged 19 and older. Not Covered Not Covered SUMMARY OF PHARMACY BENEFITS The Summary of Pharmacy Benefits only applies to prescription drugs purchased at a retail, mail order, or specialty. For information about our pharmacy network, visit our website or call our Customer Service Departmentpharmacy.
Appears in 1 contract
Samples: Subscriber Agreement
