You Pay You Pay. Acupuncture Services In a provider's office - One initial evaluation per provider per plan year and acupuncture treatments up to a combined total of 12 visits per member per plan year. $45 - After deductible The level of coverage is the same as network provider. Ambulance Services Ground $50 The level of coverage is the same as network provider. Air/water* - Up to the benefit limit of $3,000 per occurrence. 10% - After deductible The level of coverage is the same as network provider.
You Pay You Pay. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 10% - After deductible Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 10% - After deductible Not Covered Dental Care (Pediatric) - for members under age 19 See Dental Services in Section 3 for benefit limits and details. These services only apply to an enrolled member under the age of 19. Oral evaluations 0% Not Covered X-rays 0% Not Covered Cleanings (prophylaxis) 0% Not Covered Fluoride treatments 0% Not Covered Sealants 0% Not Covered Space Maintainers 0% Not Covered Palliative treatment 50% - After deductible Not Covered Fillings 50% - After deductible Not Covered Simple extractions 50% - After deductible Not Covered Denture repairs and relines/rebasing 50% - After deductible Not Covered Crowns & onlays 50% - After deductible Not Covered Therapeutic Pulpotomies 50% - After deductible Not Covered Root canal therapy 50% - After deductible Not Covered Non-surgical periodontal services 50% - After deductible Not Covered Surgical periodontal services 50% - After deductible Not Covered Periodontal maintenance 50% - After deductible Not Covered Fixed bridges and dentures 50% - After deductible Not Covered Implants 50% - After deductible Not Covered Oral surgery services 50% - After deductible Not Covered General anesthesia or IV sedation - dental office 50% - After deductible Not Covered Biopsies 50% - After deductible Not Covered Occlusal (night) guards 50% - After deductible Not Covered Orthodontic services (braces) - when medically necessary. 50% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 10% - After deductible Not Covered Durable Medical Equipment (DME), Medical Supplies, Diabetic Supplies, Prosthetic Devices, and Enteral Formula or Food, Hair Prosthetics Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 10% - After deductible Not Covered Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 10% - After deductible Not Covered Outpatient diabetic supplies/equipment purchased at licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 10% - After deductible Not Covered Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 10% - After deductible Not Covered Enteral form...
You Pay You Pay. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. $25 - After deductible Not Covered Dental Services - Outpatient Services connected to dental care when performed in an outpatient facility * 0% - After deductible Not Covered Dialysis Services Inpatient/outpatient/in your home 0% - After deductible Not Covered
You Pay You Pay. Pregnancy and Maternity Services Pre-natal, delivery, and postpartum services. 0% - After deductible 20% - After deductible 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 pharmacy. Prescription drugs dispensed and administered by a licensed health care provider (other than a pharmacist), and not purchased from a retail, specialty or mail order pharmacy: Injectable drugs* 0% - After deductible 20% - After deductible Infused drugs* 0% - After deductible 20% - After deductible Medications other than injected and infused drugs* Are included in the allowance for the medical service being rendered. Are included in the allowance for the medical service being rendered.
You Pay You Pay. Pregnancy and Maternity Services Pre-natal, delivery, and postpartum services. 0% - After deductible 20% - After deductible Prescription Drugs and Diabetic Equipment and Supplies 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
You Pay You Pay. Outpatient hospital (after the first 30 days) or in a doctor’s/therapist’s office. Limited to thirty (30) physical therapy visits and 30 occupational therapy visits per member per plan year. 20% - After deductible 20% - After deductible
