SUMMARY OF MEDICAL BENEFITS. This is a summary of your medical benefit coverage levels under this agreement. It includes information about copayments, deductibles (if any), and some benefit limits. This summary is intended to give you a general understanding of the medical coverage available under this agreement. Please read Section 3.0 for a detailed description of coverage for each particular covered health care service, along with the related exclusions.
SUMMARY OF MEDICAL BENEFITS. Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers Ground $50 The level of coverage is the same as network provider. Air/water* $50 The level of coverage is the same as network provider.
SUMMARY OF MEDICAL BENEFITS. 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 Ground $50 The level of coverage is the same as network provider. Air/water* $50 The level of coverage is the same as network provider.
SUMMARY OF MEDICAL BENEFITS. Your Plan: VantageBlue
SUMMARY OF MEDICAL BENEFITS. Your Plan: VantageBlue SelectRI This Summary of Benefits is part of your Subscriber Agreement. It describes the cost share amounts you must pay for covered services. Some benefit limits are provided here with additional benefit limits provided in the Covered Health Care Services section mentioned below. Do not rely on this chart alone. Be sure to read all parts of your Subscriber Agreement to understand the requirements you must follow to receive all of your coverage. For a full description of benefit limits, covered services and exclusions please see: • Summary of Pharmacy Benefits for benefit coverage levels of prescription drugs and diabetic equipment/supplies purchased at a pharmacy; • Covered Health Care Services - Section 3; • Health Care Services Not Covered Under This Agreement – Section 4; • Glossary – Section 8, for definitions of italicized words or phrases used throughout this *Preauthorization is recommended for services marked with an asterisk (*). Please see IMPORTANT NOTE: All of our payments at the benefit levels noted below are based upon a fee schedule called our allowance. If you receive services from a network provider, the provider has agreed to accept our allowance as payment in full for covered health care services, excluding your copayments, deductible (if any), and the difference between the maximum benefit and our allowance, if any. If you receive covered health care services from a non-network provider, you will be responsible for the provider’s charge. You will then be reimbursed based on the lesser of the provider’s charge, our allowance, or the maximum benefit, less any copayments and deductibles (if any), if any. The deductible (if any) and maximum out-of-pocket expenses are calculated based on the lower of our allowance or the provider’s charge, unless otherwise specifically stated in this agreement.
SUMMARY OF MEDICAL BENEFITS. 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 Ambulance Services Ground 0%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Air/wate*r 0%- Afterdeductible The level of coverage is the same as network xxxxxx.xx Applied behavioral analysis Preauthorizationmay be required for services received fro a non-network xxxxxx.xx 0%- Afterdeductible 40%- Afterdeductible Physical/Occupational/Speech Therapy Servi-cAesutism Diagnosis- Outpatient Hospital 0%- Afterdeductible 40%- Afterdeductible Physical/Occupational/Speech Therapy Servi-cAesutism Diagnosis- In aprovider’soffice 0%- Afterdeductible 40%- Afterdeductible Behavioral Health Services M† ental Health and Substance Use Disorder Inpatient- Unlimited days at a generhaol spitalor a specialtyhospitalincluding detoxification or residential/rehabilitation ppelran year. Preauthorizationmay be required for services received fro a non-network provider. 0%- Afterdeductible 40%- Afterdeductible Outpatientor intermediate care servic*es- See Covered Healthcare Services: Behavioral Health Section for deta about partial hospital program, intensive outpatient prog adult intensive services, and child and family intensive treatment. Preauthorizationmaybe required for services received fro a non-network provider. 0%- Afterdeductible 40%- Afterdeductible Office visit-sSee Office Visits section below for Behavio Health services provided byPaCP or specialist. Psychological Testing 0%- Afterdeductible 40%- Afterdeductible Medicatio-nassisted treatment- when rendered by a mental health or substance use disordeprrovide.r 0%- Afterdeductible 40%- Afterdeductible Methadone maintenance treatme-not ne copaymentper seven day period of treatment. 0%- Afterdeductible 40%- Afterdeductible Cardiac Rehabilitation Outpatient- Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. 0%- Afterdeductible 40%- Afterdeductible In aphysician’soffice- limited to 20 visits ppelran year. 0%- Afterdeductible 40%- Afterdeductible
SUMMARY OF MEDICAL BENEFITS. Covered Benefits - See Covered Healthcare Services for additional benefit limits and details. Network Providers Non-network Providers In a provider's office - One initial evaluation per provider per plan year and acupuncture treatments without electrical stimulation up to a combined total of 12 visits per member per plan year. $45 Not Covered Ground $50 The level of coverage is the same as network provider. Air/water* - Up to the benefit limit of $3,000 per occurrence. $50 The level of coverage is the same as network provider.
SUMMARY OF MEDICAL BENEFITS. Your Plan: BlueCHiP Flex
SUMMARY OF MEDICAL BENEFITS. This Summary of Benefits is part of your Subscriber Agreement. It describes the cost share amounts you must pay for covered services. Some benefit limits are provided here with additional benefit limits provided in the Covered Health Care Services section mentioned below. Do not rely on this chart alone. Be sure to read all parts of your Subscriber Agreement to understand the requirements you must follow to receive all of your coverage. For a full description of benefit limits, covered services and exclusions please see: Summary of Pharmacy Benefits for benefit coverage levels of prescription drugs and diabetic equipment/supplies purchased at a pharmacy; Covered Health Care Services - Section 3; Health Care Services Not Covered Under This Agreement – Section 4; Glossary – Section 8, for definitions of italicized words or phrases used throughout this *Preauthorization is recommended for services marked with an asterisk (*). Please see
SUMMARY OF MEDICAL BENEFITS. SG-COC-2-2023-BX & SG-SOB-16-2023-BX 10 BlueSolutions for HSA 1500.3000
