Services and Prosthetics a. See all exclusions.*
Services and Prosthetics. (excluding arm and leg prosthetics) 90% of eligible charges after the deductible. 80% of eligible charges after the deductible. • Arm and Leg Prosthetics 90% of eligible charges. Deductible waived. 80% of eligible charges. Deductible waived. Emergency Room Services 90% of eligible charges after the deductible. Same as the PPO Provider Plan Payment. Home Health Services 90% of eligible charges after the deductible. 80% of eligible charges after the deductible. Hospice Care 90% of eligible charges after the deductible. 80% of eligible charges after the deductible. Hospital Services Outpatient Hospital Services, Ambulatory Care or Surgical Facility Services 90% of eligible charges after the deductible. 80% of eligible charges after the deductible. Inpatient Hospital Services 90% of eligible charges after the deductible. 80% of eligible charges after the deductible. Infertility Services - limited to a lifetime benefit maximum of $10,000 for infertility transfer procedures Inpatient and Outpatient Hospital Services: 90% of eligible charges after the deductible. Office and Urgent Care Center Visits: 90% of eligible charges. Deductible waived. Inpatient and Outpatient Hospital Services: 80% of eligible charges after the deductible. Office and Urgent Care Center Visits: 80% of eligible charges. Deductible waived. Mental Health and Substance Related Services Inpatient Hospital Services: 90% of eligible charges after the deductible. Outpatient Hospital Services: 90% of eligible charges. Deductible waived. Office and Urgent Care Center Visits: 90% of eligible charges. Deductible waived. Inpatient Hospital Services: 80% of eligible charges after the deductible. Outpatient Hospital Services: 80% of eligible charges. Deductible waived. Office and Urgent Care Center Visits: 80% of eligible charges. Deductible waived. Office and Urgent Care Center Visits 90% of eligible charges. Deductible waived. 80% of eligible charges. Deductible waived. Physical Therapy, Occupational Therapy and Speech Therapy Outpatient Hospital Services: 90% of eligible charges after the deductible. Office and Urgent Care Center Visits: 90% of eligible charges. Deductible waived. Outpatient Hospital Services: 80% of eligible charges after the deductible. Office and Urgent Care Center Visits: 80% of eligible charges. Deductible waived. 2 Revised 1.1.19 Preventive Health Care Services • Routine Physical Exams • Routine Gynecological Exams • Routine Mammograms • Well-Child Care • Immunizations • Colono...
