Benefits Book 2014

Page 74

Options BENEFIT

Inside Network Initial hospital stay: See Hospital Services; Office visits: See Outpatient Services; Routine well care: See Preventive care. Any Newborn Services applicable cost share for newborn services is separate from that of the mother Obesity-related surgery (bariatric) Not covered Organ transplants Donor search & harvest a pplies to lifetime max

Unlimited, no waiting period

Outside Network Initial hospital stay: See Hospital Services; Office visits: See Outpatient Services; Routine well care: See Preventive care. Any applicable cost share for newborn services is separate from that of the mother Not covered Shared with in-network

Inpatient: $100 copay, per day for Inpatient: $100 copay, per day for up to 5 days per admit Deductible up to 5 days per admit and coinsurance apply Outpatient: $15 copay

Outpatient: $15 copay, deductible and coinsurance apply $300 per person; $600 per family per calendar year Coinsurance applies

Preventive care Well-care physicals, immunizations, Pap smear exams, mammograms

Rehabilitation services (Occupational, speech, physical including services for neurodevelopmentally disabled members) Rehabilitation visits are a total of combined therapy visits per calendar year Skilled nursing facility

Sterilization (vasectomy, tubal ligation)

Temporomandibular Joint (TMJ) services

Tobacco cessation counseling Routine vision care (1 visit every 12 months) Optical hardware Lenses, including contact lenses and frames

RQ-68054

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MYSEIUBENEFITS.ORG

Covered in full Women’s preventive care services (including contraceptive drugs and devices and sterilization) are covered in full.

Inpatient: 60 days per calendar year $100 copay, per day for up to 5 days per admit

Women’s preventive care services (including contraceptive drugs and devices and sterilization) are subject to the applicable Preventive Care cost share and benefit maximums Routine mammograms: Deductible and coinsurance apply Inpatient: Day limits shared with in-network $100 copay, per day for up to 5 days per admit Deductible and coinsurance apply

Outpatient: 60 visits per calendar year $15 copay

Outpatient: Visit limits shared with in-network $15 copay, deductible and coinsurance apply Day limits shared with in-network Covered in full up to 60 days per benefit, deductible and coinsurance calendar year apply Inpatient: $100 copay, per day for up to 5 days per admit Inpatient: $100 copay, per day for Deductible and coinsurance apply up to 5 days per admit Outpatient: $15 copay, deductible and coinsurance apply Outpatient: $15 copay

Women’s sterilization procedures are covered subject to the applicable Preventive Care cost share and benefit maximums Shared with in-network $1,000 per calendar year; $5,000 Inpatient: $100 copy, per day for up lifetime max to 5 days per admit Inpatient: $100 copay, per day for Deductible and coinsurance apply up to 5 days per admit Outpatient: $15 copay, deductible Outpatient: $15 copay and coinsurance apply Quit for Life Program - covered Applicable cost shares apply in full $15 copay, deductible and $15 copay coinsurance apply Women’s sterilization procedures are covered in full.

$200 per 24 months

Shared with in-network


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