Schedule of Medical Benefits 2014 - 2015 Medical Plan Service
In-Network Copay/Coinsurance
Out-of-Network Coinsurance
0% (no deductible)
35%
0% (no deductible) Max: 8 visits/yr
Not covered
Miscellaneous Services cont. PKU Supplies
(Includes treatment & medical foods)
Dietary/Nutritional Counseling (Prior authorization recommended)
Obesity Management (Prior authorization required by all plans)
25%
Must be enrolled in Take Control for non-surgical treatment
25%
TMJ
Surgical treatment only
(Prior authorization required)
Infertility Treatment (biological infertility only) (prior authorization required for all plans providing coverage)
Not covered
Not covered
25% Max: 3 artificial inseminations/ lifetime
Not covered
25%
Not covered
Organ Transplants Transplant Services (Prior authorization required)
Travel 0%
Travel for patient only (if services are not available in local community)
up to $1,500/yr. with Prior authorization -up to $5,000/yr. in conjunction with transplants only with Prior authorization
Get Healthy, Stay Healthy Preventive Health Screenings/ Healthy Lifestyle Ed. & Support/ Emotional & Financial Wellness
see pg 29
Take Control Tobacco Cessation, Diabetes, Weight Loss, High Cholesterol, High Blood Pressure
see pg 30
WellBaby Infusion Therapy
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Not covered