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
74
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