Schedule of Medical Benefits Medical Plan Services
FY2020
In-Network Copay/Coinsurance
Out-of-Network Coinsurance
0% (no deductible)
40%
First 8 visits $0 copay, then $30 copay/visit
40%
Miscellaneous Services cont. PKU Supplies
(Includes treatment & medical foods)
Dietary/Nutritional Counseling
Obesity Management (Prior Authorization required for surgical treatment)
30%
Must be enrolled in Take Control for non-surgical treatment
30%
TMJ
(Prior Authorization recommended)
40%
Surgical treatment only
40%
30%
40%
0%
0%
Organ Transplants Transplant Services (Prior Authorization required)
Travel Travel for patient only - If services are not available in local area (Prior Authorization required)
up to $1,500/yr.
-up to $5,000/transplant
up to $1,500/yr.
-up to $5,000/transplant
Wellness Program Preventive Health Screenings Healthy Lifestyle Ed. & Support WellBaby Take Control Diabetes, Weight Loss, High Cholesterol, High Blood Pressure, Tobacco User
Reminder:
see pg 22
Deductible applies to all covered services unless otherwise indicated or a copay applies. Out-of-Network providers can balance bill the difference between their charge and the allowed amount.
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