Prevention and Early Detection Services. Prevention and early detection services See Prevention and Early Detection Services section for details. 0% 20% - After Deductible
Prevention and Early Detection Services. Prevention and early detection services See Prevention and Early Detection Services section for details. 0% 40% - After Deductible Private duty nursing* Must be performed by a certified home health care agency. 20% - After Deductible 40% - After Deductible
Prevention and Early Detection Services. Genetic Counseling for BRCA Must be performed by a certified genetic counselor. 0% NO 0% NO 70% YES Contracep- tive and Sterilization Services for women Prescription drugs, dispensed and administered by a licensed health care provider (other than a pharmacist). For prescription drugs purchased at a pharmacy, see the Summary of Pharmacy Benefits. 0% NO 0% NO 70% YES Barrier method (cervical cap or diaphragm) fitted and supplied during an office visit. 0% NO 0% NO 70% YES Surgical services, including but not limited to, tubal ligation and insertion/removal of IUD. 0% NO 0% NO 70% YES Manual breast pumps In conjunction with birth. 0% NO 0% NO 70% YES Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Private Duty Nursing* Must be performed by a certified home health care agency. 30% YES 30% YES 70% YES Radiation Therapy/ Chemo-therapy Services Outpatient 30% YES 30% YES 70% YES In a doctor’s office 30% YES 30% YES 70% YES Respiratory Therapy 30% YES 30% YES 70% YES Skilled Nursing Facility Care Skilled or Sub-acute 30% YES 30% YES 70% YES Speech Therapy * ^ In a doctor’s/ therapist’s office* Covered health care services include rehabilitative and habilitative services. $25 NO $25 NO 70% YES Outpatient hospital * Covered health care services include rehabilitative and habilitative services. $75 NO $75 NO 70% YES Surgery Services Inpatient Facility See Inpatient Hospital Services Inpatient Doctor 30% YES 30% YES 70% YES Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Surgery Services Outpatient- hospital , ambulatory or independent surgical center 30% YES 30% YES 70% YES In a doctor’s office 0% NO 0% NO 70% YES Tests, Imaging*, and Labs (includes machine tests and x-rays)...
Prevention and Early Detection Services. Prevention and early detection services See Prevention and Early Detection Services section for details. 0% 0% 50% - After Deductible Private duty nursing* Must be performed by a certified home health care agency. 0% - After Deductible 0% - After Deductible 50% - After Deductible Outpatient 0% - After Deductible 0% - After Deductible 50% - After Deductible In a doctor’s office 0% - After Deductible 0% - After Deductible 50% - After Deductible Respiratory Therapy 0% - After Deductible 0% - After Deductible 50% - After Deductible Skilled or sub-acute care* 0% - After Deductible 0% - After Deductible 50% - After Deductible Limited to thirty (30) visits per member per plan year. Covered health care services include rehabilitative and habilitative services: In a doctor’s/therapist’s office* $25 $25 50% - After Deductible Outpatient Hospital* $75 $75 50% - After Deductible Covered Benefits Network Providers You Pay Non-network Providers You Pay
Prevention and Early Detection Services. In accordance with the guidelines established by the ACS and in accordance with Rhode Island General Laws § 27-20-17 and § 27-20-44, this agreement provides coverage for prevention and early detection services such as, but not limited to, office visits, surgical procedures, electrocardiograms, and cancer screenings. The list of covered services is based on the most current ACS guidelines and is subject to change. Except for certain cancer screenings as mentioned below, the level of coverage for prevention and early detection services is based on the type of service. For information regarding office visits see Section 3.24- Office Visits, for surgical procedures see Section 3.36 - Surgery Services, and for lab, radiology, and machine tests see Section 3.8 - Diagnostic Imaging, Lab, and Machine Tests. See the Summary of Benefits for benefit limits and level of coverage for each type of service. For the purpose of coverage under this agreement, the benefit limit and level of coverage listed in the Summary of Benefits for Prevention and Early Detection Services/ Cancer Screenings applies to the following cancer screenings:
(a) Mammograms
(b) Pap Smears
(c) Prostate Specific Antigen (PSA) test See the Summary of Benefits for benefit limits and level of coverage. We cover adult preventive vaccinations/immunizations for Diphtheria – Tetanus (or tetanus alone), Influenza, Pneumonia, Hepatitis A and Hepatitis B. Our allowance includes the administration and the vaccine. See the Summary of Benefits for benefit limits and level of coverage. If any of the above immunizations are provided as part of an office visit, only your office visit copayment and/or deductible will be applied. If your doctor administers any of the above immunizations/vaccinations in the absence of an office visit, the immunization is covered up to the benefit level stated in the Summary of Benefits.
Prevention and Early Detection Services. Preventive office visits Includes adult annual, well woman annual and pediatric office/clinic visits. 0% 20% plus $25 – After Deductible Preventive counseling/education Includes diabetes education, nutritional counseling and smoking cessation counseling and genetic counseling for BRCA. 0% 20% plus $25 - After Deductible Immunizations Includes adult, pediatric and travel immunizations. 0% 20% - After Deductible Preventive Screenings 0% 20% - After Deductible Contraceptive and Sterilization services for women 0% 20% - After Deductible Breast pumps 0% 20% - After Deductible
Prevention and Early Detection Services. Prevention and early detection services See Prevention and Early Detection Services section for details. Preventive office visits Includes adult annual and pediatric office/clinic visits. 0% 20% plus $25 – After Deductible Well woman annual visit 0% 20% plus $40 – After Deductible Preventive counseling/education Includes diabetes education, nutritional counseling and smoking cessation counseling and genetic counseling for BRCA. 0% 20% plus $40 - After Deductible Immunizations Includes adult, pediatric and travel immunizations. 0% 20% - After Deductible Preventive Screenings 0% 20% - After Deductible Contraceptive and Sterilization services for women 0% 20% - After Deductible Breast pumps 0% 20% - After Deductible Private duty nursing* Must be performed by a certified home health care agency. 20% - After Deductible 20% - After Deductible
