MMC Benefits Handbook
Detailed List of Covered Services
The Plan reimburses medically necessary covered services and supplies for the diagnosis and treatment for an illness or injury. The Claims Administrator determines whether the service or supply is covered and determines the amount to be reimbursed.
Most services and supplies are subject to a deductible and coinsurance.
Your costs for out-of-network services apply toward the in-network deductible and out-of-pocket maximum. However, your costs for in-network services do not apply toward the out-of-network deductible and out-of-pocket maximum.
$400 Deductible Plan and $900 Deductible Plan
 
$400 Deductible Plan
$900 Deductible Plan
Services
In-Network Coverage
Out-of-Network Coverage
In-Network Coverage
Out-of-Network Coverage
Alcohol and substance use
Inpatient and Residential Treatment:
80% after deductible Preauthorization is required
Outpatient:
$20 per visit (no deductible)
Inpatient and Residential Treatment:
60% of R&C after deductible Preauthorization is required
Outpatient:
60% after deductible
Inpatient and Residential Treatment:
80% after deductible Preauthorization is required
Outpatient:
80% after deductible
Inpatient and Residential Treatment:
60% of R&C after deductible Preauthorization is required
Outpatient:
60% after deductible
Allergy testing and treatment
PCP: $20 per visit; Specialist: $40 per visit
60% of R&C after deductible
80% after deductible
60% of R&C after deductible
Alternative medicine (Acupuncture)
Coverage limitations:
  • Performed by a physician as a form of anesthesia in connection with surgery or dental procedure that is covered under the Plan.
  • A form of Alternative Treatment as long as it is rendered by a certified/licensed individual.
  • Limited to 12 visits per calendar year (combined in-network/out-of-network).
Coverage limitations:
  • Performed by a physician as a form of anesthesia in connection with surgery or dental procedure that is covered under the Plan.
  • A form of Alternative Treatment as long as it is rendered by a certified/licensed individual.
  • Limited to 12 visits per calendar year (combined in-network/out-of-network).
Ambulance charges
80% after deductible
80% of R&C after deductible
80% after deductible
80% of R&C after deductible
Artificial insemination
$40 copay (no deductible) if service is performed in an office
All other places of service: 80% after deductible
Limited to overall infertility maximum of $15,000 per lifetime
Preauthorization required
60% of R&C after deductible
Limited to overall infertility maximum of $15,000 per lifetime
Preauthorization required
80% after deductible
Limited to overall infertility maximum of $15,000 per lifetime
Preauthorization required
60% of R&C after deductible
Limited to overall infertility maximum $15,000 per lifetime
Preauthorization required
CAT / PET scans
80% after deductible
CAT scans subject to preauthorization
60% of R&C after deductible
80% after deductible
CAT scans subject to preauthorization
60% of R&C after deductible
Chiropractors
$40 per visit (no deductible)
30 visits per calendar year (combined in-network/out-of-network)
60% of R&C after deductible for up to 30 visits per calendar year (combined in-network/out-of-network)
80% after deductible for up to 30 visits per calendar year (combined in-network/out-of-network)
60% of R&C after deductible for up to 30 visits per calendar year (combined in-network/out-of-network)
Contraceptive devices (as defined as Preventive Prescriptions)
Covered at 100%, without deductible
60% of R&C after deductible
Covered at 100%, without deductible
60% of R&C after deductible
Cosmetic surgery
Not covered
Not covered
Not covered
Not covered
Dental treatment
(covered only for accidental injury to sound teeth within 12 months)
80% after deductible; subject to office visit copay in office
60% of R&C after deductible
80% after deductible
60% of R&C after deductible
Doctor delivery charge for newborns
80% after deductible
60% of R&C after deductible
80% after deductible
60% of R&C after deductible
Durable medical equipment (DME)
80% after deductible
Preauthorization is required for purchase or rentals of certain DME
60% of R&C after deductible
Preauthorization is required for purchase or rentals of certain DME
80% after deductible
Preauthorization is required for purchase or rentals of certain DME
60% of R&C after deductible
Preauthorization is required for purchase or rentals of certain DME
EKG Testing
Covered at 100% (not subject to deductible). Considered preventive if performed as part of a routine exam or associated with a preventive diagnosis code.
60% of R&C after deductible. Considered preventive if performed as part of a routine exam or associated with a preventive diagnosis code.
Covered at 100% (not subject to deductible). Considered preventive if performed as part of a routine exam or associated with a preventive diagnosis code.
60% of R&C after deductible. Considered preventive if performed as part of a routine exam or associated with a preventive diagnosis code.
Emergency room
$150, then 80% after deductible for life-threatening injury or illness (See "Life-threatening Illness or Injury in the "Glossary").
$150, then 80% of R&C after deductible for life-threatening injury or illness (See "Life-threatening Illness or Injury in the "Glossary").
80% after deductible for life-threatening injury or illness (See "Life-threatening Illness or Injury in the "Glossary").
80% of R&C after deductible for life-threatening injury or illness (See "Life-threatening Illness or Injury in the "Glossary").
Gender Reassignment Surgery (and related costs)
80% after deductible
Services in physician office subject to copayment
Call the Claims Administrator at the number on the back of your ID card for specifics on what is covered and excluded by the Plan.
Preauthorization is required for inpatient services
60% of R&C after deductible
Call the Claims Administrator at the number on the back of your ID card for specifics on what is covered and excluded by the Plan.
Preauthorization is required for inpatient services
80% after deductible
Call the Claims Administrator at the number on the back of your ID card for specifics on what is covered and excluded by the Plan.
Preauthorization is required for inpatient services
60% of R&C after deductible
Call the Claims Administrator at the number on the back of your ID card for specifics on what is covered and excluded by the Plan.
Preauthorization is required for inpatient services
Gynecology visits
Covered at 100% (not subject to deductible) for one routine exam each calendar year
Subsequent visits – $20 copay
60% of R&C after deductible
Covered at 100% (not subject to deductible) for one routine exam each calendar year
Subsequent visits – 80% after deductible
60% of R&C after deductible
Hearing care
80% after deductible; subject to office visit copays
Routine hearing screenings performed by a PCP (such as whispered voice, tuning fork), which do not utilize calibrated instrument are covered at 100% when provided as part of a preventive/wellness visit. Hearing exams utilizing calibrated instruments not covered. Covered hearing aids limited to $1,000 a year per ear
60% of R&C after deductible
Covered hearing aids limited to $1,000 a year per ear.
80% after deductible; subject to office visit copays
Routine hearing screenings performed by a PCP (such as whispered voice, tuning fork), which do not utilize calibrated instruments are covered at 100% when provided as part of a preventive/wellness visit. Hearing exams utilizing calibrated instruments not covered. Covered hearing aids limited to $1,000 a year per ear
60% of R&C after deductible
Covered hearing aids limited to $1,000 a year per ear.
Home health care
80% after deductible for up to 120 home health care aid visits per calendar year for homebound patients Preauthorization is required
60% of R&C after deductible for up to 120 home health care aid visits per calendar year for homebound patients Preauthorization is required
80% after deductible for up to 120 home health care aid visits per calendar year for homebound patients Preauthorization is required
60% of R&C after deductible for up to 120 home health care aid visits per calendar year for homebound patients Preauthorization is required
Hospice care
80% after deductible
Preauthorization is required
60% of R&C after deductible
Preauthorization is required
80% after deductible
Preauthorization is required
60% of R&C after deductible
Preauthorization is required
Immunizations
(routine)
Covered at 100% (not subject to deductible)
60% of R&C after deductible
Covered at 100% (not subject to deductible)
60% of R&C after deductible
Infertility Services
$40 copay (no deductible) if service is performed in an office
80% after deductible for all other places of service
Artificial Insemination and Advanced Reproductive Technology are limited to overall infertility maximum of $15,000 per lifetime maximum (combined in-network/out-of-network)
Coverage requires a diagnosis of infertility. Claims prior to 01/01/2015 will not apply to the lifetime maximum on new plans. Preauthorization required
60% of R&C after deductible
Artificial Insemination and Advanced Reproductive Technology are limited to overall infertility maximum of $15,000 per lifetime maximum (combined in-network/out-of-network)
Coverage requires a diagnosis of infertility. Claims prior to 01/01/2015 will not apply to the lifetime maximum on new plans. Preauthorization required
80% after deductible
Artificial Insemination and Advanced Reproductive Technology are limited to overall infertility maximum of $15,000 per lifetime maximum (combined in-network/out-of-network)
Coverage requires a diagnosis of infertility. Claims prior to 01/01/2015 will not apply to the lifetime maximum on new plans. Preauthorization required
60% of R&C after deductible
Artificial Insemination and Advanced Reproductive Technology are limited to overall infertility maximum of $15,000 per lifetime maximum (combined in-network/out-of-network)
Coverage requires a diagnosis of infertility. Claims prior to 01/01/2015 will not apply to the lifetime maximum on new plans. Preauthorization required
Inpatient hospital services
80% after deductible
Preauthorization is required
60% of R&C after deductible
Preauthorization is required
80% after deductible
Preauthorization is required
60% of R&C after deductible
Preauthorization is required
Laboratory charges
80% after deductible
60% of R&C after deductible
80% after deductible
60% of R&C after deductible
Magnetic resonance imaging – MRI
80% after deductible
Preauthorization is required for MRIs
60% of R&C after deductible
is required
80% after deductible
Preauthorization is required for MRIs
60% of R&C after deductible
is required
Mammograms, including 3D mammograms (Routine)
Covered at 100% (not subject to deductible)
60% of R&C after deductible
Covered at 100% (not subject to deductible)
60% of R&C after deductible
Mastectomy – reconstructive surgery
80% after deductible
60% of R&C after deductible
80% after deductible
60% of R&C after deductible
Maternity hospital stay
80% after deductible
60% of R&C after deductible
80% after deductible
60% of R&C after deductible
Mental health
Inpatient and Residential Treatment
80% after deductible
Subject to preauthorization
Outpatient:
$20 per visit
Inpatient and Residential Treatment
60% after deductible
Subject to preauthorization
Outpatient:
60% after deductible
Inpatient and Residential Treatment
80% after deductible
Subject to preauthorization
Outpatient:
80% after deductible
Inpatient and Residential Treatment
60% after deductible
Subject to preauthorization
Outpatient:
60% after deductible
Obesity Surgery
80% after deductible
Copays apply if there are office visits
Once per lifetime
All services must be obtained from a recognized in-network IOQ.
All services must be obtained from a recognized in-network IOQ.
80% after deductible
Once per lifetime
All services must be obtained from a recognized in-network IOQ
All services must be obtained from a recognized in-network IOQ.
Occupational therapy
$40 per visit.1 Medical Necessity Required.
60% of R&C after deductible. Medical Necessity Required.
80% after deductible. Medical Necessity Required.
60% of R&C after deductible. Medical Necessity Required.
Organ transplant
100% after deductible in IOQ as determined by the Claims Administrator. 80% after deductible Non- IOQPreauthorization is required
60% of R&C after deductible
Preauthorization is required
100% after deductible in IOQ (as determined by the Claims Administrator)
80% after deductible Non-IOQ Preauthorization is required
60% of R&C after deductible
Preauthorization is required
Outpatient physician services
Preventive: 100%
PCP: $20 per visit
Mental Health/Substance Use Disorder: $20 per visit
Specialist: $40 per visit
Outpatient facility 80% after deductible
60% of R&C after deductible
Preventive: 100%
Non-preventive: 80% after deductible
60% of R&C after deductible
Physical exams for adults
(routine)
Covered at 100% (not subject to deductible or copays) for one physical exam each calendar year
60% of R&C after deductible for one physical exam each calendar year
Covered at 100% (not subject to deductible) for one physical exam each calendar year
60% of R&C after deductible for one physical exam each calendar year
Physical exams for children
(routine)
Covered at 100% (not subject to deductible or copays)
Subject to Plan limits
60% of R&C after deductible
Subject to Plan limits
Covered at 100% (not subject to deductible)
Subject to Plan limits
60% of R&C after deductible
Subject to Plan limits
Physical therapy
$40 per visit.2 Medical Necessity Required.
60% of R&C after deductible. Medical Necessity Required.
80% after deductible. Medical Necessity Required.
60% of R&C after deductible. Medical Necessity Required.
Pregnancy termination
Subject to office visit copay, with no deductible in office
80% after deductible in other places of service
60% of R&C after deductible
80% after deductible
60% of R&C after deductible
Prenatal visits
$20 copay (not subject to deductible) for first visit
Routine Prenatal Care covered at 100%
60% of R&C after deductible
80% after deductible first visit only Routine Prenatal Care covered at 100%
60% of R&C after deductible
Private Duty Nursing
80% after deductible
Maximum of 60 visits (8-hour shifts) per calendar year
(Combined in-network/out-of-network)
Preauthorization is required
60% of R&C after deductible
Maximum of 60 visits (8-hour shifts) per calendar year
(Combined in-network/out-of-network)
Preauthorization is required
80% after deductible
Maximum of 60 visits (8-hour shifts) per calendar year
(Combined in-network/out-of-network)
Preauthorization is required
60% of R&C after deductible
Maximum of 60 visits (8-hour shifts) per calendar year
(Combined in-network/out-of-network)
Preauthorization is required
Prostate specific antigen test–- PSA
(routine)
Covered at 100% (not subject to deductible or copay)
60% of R&C after deductible
Covered at 100% (not subject to deductible)
60% of R&C after deductible
Prescription drugs (see "Drugs"
There is a pharmacy network for retail and mail order prescription drugs.
There is a pharmacy network for retail and mail order prescription drugs.
There is a pharmacy network for retail and mail order prescription drugs.
There is a pharmacy network for retail and mail order prescription drugs.
Skilled nursing facility
80% after deductible for up to 120 days per calendar year (combined in-network/out-of-network)
Preauthorization is required
60% of R&C after deductible for up to 120 days per calendar year (combined in-network/out-of-network)
Preauthorization is required
80% after deductible for up to 120 days per calendar year (combined in-network/out-of-network)
Preauthorization is required
60% of R&C after deductible for up to 120 days per calendar year (combined in-network/out-of-network)
Preauthorization is required
Speech therapy
$40 per visit.3 Medical Necessity Required.
60% of R&C after deductible. Medical Necessity Required.
80% after deductible. Medical Necessity Required.
60% of R&C after deductible. Medical Necessity Required.
Surgery
80% after deductible
Preauthorization is required if in-patient
Predetermination of benefits is recommended for multiple surgical procedures
60% of R&C after deductible
Preauthorization is required if in-patient
Predetermination of benefits is recommended for multiple surgical procedures
80% after deductible
Preauthorization is required if in-patient
Predetermination of benefits is recommended for multiple surgical procedures
60% of R&C after deductible
Preauthorization is required if in-patient
Predetermination of benefits is recommended for multiple surgical procedures
Tubal ligation
Covered at 100%, deductible does not apply
60% of R&C after deductible
Covered at 100%, deductible does not apply
60% of R&C after deductible
Urgent Care
$50 per visit, deductible does not apply
60% of R&C after deductible
80% after deductible
60% of R&C after deductible
Virtual Medicine
$20 copay per visit
Not covered
80% after deductible
Not covered
Vasectomy
80% after deductible; subject to office visit copay if performed in an office
60% of R&C after deductible
80% after deductible
60% of R&C after deductible
Vision care
(routine eye exam)
Not covered
Not covered
Not covered
Not covered
Vision Therapy/
Orthoptics
$40 copay per visit (maximum of 12 vision therapy visits or sessions medically necessary for treatment of convergence insufficiency)
60% of R&C after deductible (maximum of 12 vision therapy visits or sessions medically necessary for treatment of convergence insufficiency)
80% of R&C after deductible (maximum of 12 vision therapy visits or sessions medically necessary for treatment of convergence insufficiency)
60% of R&C after deductible (maximum of 12 vision therapy visits or sessions medically necessary for treatment of convergence insufficiency)
X-rays
80% after deductible
60% of R&C after deductible
80% after deductible
60% of R&C after deductible
1 $20 per visit if Occupational Therapy is a treatment for autism spectrum disorder (ASD).
2 $20 per visit if treatment is for Autism Spectrum Disorder (ASD).
3 $20 per visit if treatment is for autism spectrum disorder (ASD).
$1,500 Deductible Plan and $2,850 Deductible Plan
 
$1,500 Deductible Plan
$2,850 Deductible Plan
Services
In-Network Coverage
Out-of-Network Coverage
In-Network Coverage
Out-of-Network Coverage
Alcohol and substance use
Inpatient and Residential Treatment:
80% after deductible Preauthorization is required
Outpatient:
80% after deductible
Inpatient and Residential Treatment:
60% of R&C after deductible Preauthorization is required
Outpatient:
60% after deductible
Inpatient and Residential Treatment:
70% after deductible Preauthorization is required
Outpatient:
70% after deductible
Inpatient and Residential Treatment:
50% of R&C after deductible Preauthorization is required
Outpatient:
50% after deductible
Allergy testing and treatment
80% after deductible
60% of R&C after deductible
70% after deductible
50% of R&C after deductible
Alternative medicine (Acupuncture)
Coverage limitations:
  • Performed by a physician as a form of anesthesia in connection with surgery or dental procedure that is covered under the Plan.
  • A form of Alternative Treatment as long as it is rendered by a certified/licensed individual.
  • Limited to 12 visits per calendar year (combined in-network/out-of-network).
Coverage limitations:
  • Performed by a physician as a form of anesthesia in connection with surgery or dental procedure that is covered under the Plan.
  • A form of Alternative Treatment as long as it is rendered by a certified/licensed individual.
  • Limited to 12 visits per calendar year (combined in-network/out-of-network).
Ambulance charges
80% after deductible
80% of R&C after deductible
70% after deductible
70% of R&C after deductible
Artificial insemination
80% after deductible
Limited to overall infertility maximum of $15,000 per lifetime (combined in-network/out-of-network) Preauthorization required
60% of R&C after deductible
Limited to overall infertility maximum of $15,000 per lifetime (combined in-network/out-of-network) Preauthorization required
70% after deductible
Limited to overall infertility maximum of $15,000 per lifetime (combined in-network/out-of-network) Preauthorization required
50% of R&C after deductible
Limited overall infertility maximum of to $15,000 per lifetime (combined in-network/out-of-network) Preauthorization required
CAT / PET scans
80% after deductible
CAT scans subject to preauthorization
60% of R&C after deductible
70% after deductible
CAT scans subject to preauthorization
50% of R&C after deductible
Chiropractors
80% after deductible for up to 30 visits per calendar year combined in-network/out-of-network
60% of R&C after deductible for up to 30 visits per calendar year combined in-network/out-of-network
70% after deductible for up to 30 visits per calendar year combined in-network/out-of-network
50% of R&C after deductible for up to 30 visits per calendar year combined in-network/out-of-network
Contraceptive devices (as defined as Preventive Prescriptions)
Covered at 100%, without deductible
60% of R&C after deductible
Covered at 100%, without deductible
50% of R&C after deductible
Cosmetic surgery
Not covered
Not covered
Not covered
Not covered
Dental treatment
(covered only for accidental injury to sound teeth within 12 months)
80% after deductible
60% of R&C after deductible
70% after deductible
50% of R&C after deductible
Doctor delivery charge for newborns
80% after deductible
60% of R&C after deductible
70% after deductible
50% of R&C after deductible
Durable medical equipment (DME)
80% after deductible
Preauthorization is required for purchase or rentals of certain DME
60% of R&C after deductible
Preauthorization is required for purchase or rentals of certain DME
70% after deductible
Preauthorization is required for purchase or rentals of certain DME
50% of R&C after deductible
Preauthorization is required for purchase or rentals of certain DME
EKG Testing
Covered at 100% (not subject to deductible). Considered preventive if performed as part of a routine exam or associated with a preventive diagnosis code.
60% of R&C after deductible. Considered preventive if performed as part of a routine exam or associated with a preventive diagnosis code.
Covered at 100% (not subject to deductible). Considered preventive if performed as part of a routine exam or associated with a preventive diagnosis code.
50% of R&C after deductible. Considered preventive if performed as part of a routine exam or associated with a preventive diagnosis code.
Emergency room
80% after deductible for life-threatening injury or illness [(See "Life-threatening Illness or Injury in the "Glossary").
80% of R&C after deductible for life-threatening injury or illness (See "Life-threatening Illness or Injury in the "Glossary").
70% after deductible for life-threatening injury or illness (See "Life-threatening Illness or Injury in the "Glossary").
70% of R&C after deductible for life-threatening injury or illness (See "Life-threatening Illness or Injury in the "Glossary").
Gender Reassignment Surgery (and related costs)
80% after deductible
Call the Claims Administrator at the number on the back of your ID card for specifics on what is covered and excluded by the Plan.
Preauthorization is required
60% of R&C after deductible
Call the Claims Administrator at the number on the back of your ID card for specifics on what is covered and excluded by the Plan.
Preauthorization is required
70% after deductible
Call the Claims Administrator at the number on the back of your ID card for specifics on what is covered and excluded by the Plan.
Preauthorization is required
50% of R&C after deductible
Call the Claims Administrator at the number on the back of your ID card for specifics on what is covered and excluded by the Plan.
Preauthorization is required
Gynecology visits
Covered at 100% (not subject to deductible) for one routine exam each calendar year
Subsequent visits – 80% after deductible
60% of R&C after deductible
Covered at 100% (not subject to deductible) for one routine exam each calendar year
Subsequent visits – 70% after deductible
50% of R&C after deductible
Hearing care
80% after deductible; subject to office visit copays
Routine hearing screenings performed by a PCP (such as whispered voice, tuning fork), which do not utilize calibrated instrument are covered at 100% when provided as part of a preventive/wellness visit. Hearing exams utilizing calibrated instruments not covered. Covered hearing aids limited to $1,000 a year per ear
60% of R&C after deductible
Covered hearing aids limited to $1,000 a year per ear.
80% after deductible; subject to office visit copays
Routine hearing screenings performed by a PCP (such as whispered voice, tuning fork), which do not utilize calibrated instruments are covered at 100% when provided as part of a preventive/wellness visit. Hearing exams utilizing calibrated instruments not covered. Covered hearing aids limited to $1,000 a year per ear
60% of R&C after deductible
Covered hearing aids limited to $1,000 a year per ear.
Home health care
80% after deductible for up to 120 home health care aid visits per calendar year for homebound patients Preauthorization is required
60% of R&C after deductible for up to 120 home health care aid visits per calendar year for homebound patients Preauthorization is required
70% after deductible for up to 120 home health care aid visits per calendar year for homebound patients Preauthorization is required
50% of R&C after deductible for up to 120 home health care aid visits per calendar year for homebound patients Preauthorization is required
Hospice care
80% after deductible
Preauthorization is required
60% of R&C after deductible
Preauthorization is required
70% after deductible
Preauthorization is required
50% of R&C after deductible
Preauthorization is required
Immunizations
(routine)
Covered at 100% (not subject to deductible)
60% of R&C after deductible
Covered at 100% (not subject to deductible)
50% of R&C after deductible
Infertility Services
80% after deductible
Artificial Insemination and Advanced Reproductive Technology are limited to overall infertility maximum of $15,000 per lifetime maximum (combined in-network/out-of-network)
Coverage requires a diagnosis of infertility. Claims prior to 01/01/2015 will not apply to the lifetime maximum on new plans. Preauthorization required
60% of R&C after deductible
Artificial Insemination and Advanced Reproductive Technology are limited to overall infertility maximum of $15,000 per lifetime maximum (combined in-network/out-of-network)
Coverage requires a diagnosis of infertility. Claims prior to 01/01/2015 will not apply to the lifetime maximum on new plans. Preauthorization required
70% after deductible
Artificial Insemination and Advanced Reproductive Technology are limited to overall infertility maximum of $15,000 per lifetime maximum (combined in-network/out-of-network)
Coverage requires a diagnosis of infertility. Claims prior to 01/01/2015 will not apply to the lifetime maximum on new plans. Preauthorization required
50% of R&C after deductible
Artificial Insemination and Advanced Reproductive Technology are limited to overall infertility maximum of $15,000 per lifetime maximum (combined in-network/out-of-network)
Coverage requires a diagnosis of infertility. Claims prior to 01/01/2015 will not apply to the lifetime maximum on new plans. Preauthorization required
Inpatient hospital services
80% after deductible
Preauthorization is required
60% of R&C after deductible
Preauthorization is required
70% after deductible
Preauthorization is required
50% of R&C after deductible
Preauthorization is required
Laboratory charges
80% after deductible
60% of R&C after deductible
70% after deductible
50% of R&C after deductible
Magnetic resonance imaging – MRI
80% after deductible
Preauthorization is required for MRIs
60% of R&C after deductible
is required
70% after deductible
Preauthorization is required for MRIs
50% of R&C after deductible
is required
Mammograms, including 3D mammograms
(Routine)
Covered at 100% (not subject to deductible)
60% of R&C after deductible
Covered at 100% (not subject to deductible)
50% of R&C after deductible
Mastectomy – reconstructive surgery
80% after deductible
60% of R&C after deductible
70% after deductible
50% of R&C after deductible
Maternity hospital stay
80% after deductible
60% of R&C after deductible
70% after deductible
50% of R&C after deductible
Mental health
Inpatient and Residential Treatment
80% after deductible
Subject to preauthorization
Outpatient:
80% after deductible
Inpatient and Residential Treatment
60% after deductible
Subject to preauthorization
Outpatient:
60% after deductible
Inpatient and Residential Treatment
70% after deductible
Subject to preauthorization
Outpatient:
70% after deductible
Inpatient and Residential Treatment
50% after deductible
Subject to preauthorization
Outpatient:
50% after deductible
Obesity Surgery
80% after deductible
Once per lifetime
All services must be obtained from a recognized in-network
IOQ Preauthorization required
All services must be obtained from a recognized in-network
IOQ
80% after deductible
Once per lifetime
All services must be obtained from a recognized in-network
IOQ Preauthorization required
All services must be obtained from a recognized in-network
IOQ
Occupational therapy
80% after deductible. Medical Necessity Required.
60% of R&C after deductible. Medical Necessity Required.
70% after deductible. Medical Necessity Required.
50% of R&C after deductible. Medical Necessity Required.
Organ transplant
100% after deductible in IOQ as determined by the Claims Administrator 80% after deductible in Non-IOQ Preauthorization is required
60% of R&C after deductible
Preauthorization is required
100% after deductible in IOQ as determined by the Claims Administrator 70% after deductible in Non-IOQ Preauthorization is required
50% of R&C after deductible
Preauthorization is required
Outpatient physician services
80% after deductible
60% of R&C after deductible
70% after deductible
50% of R&C after deductible
Physical exams for adults
(routine)
Covered at 100% (not subject to deductible) for one physical exam each calendar year
60% of R&C after deductible for one physical exam each calendar year
Covered at 100% (not subject to deductible) for one physical exam each calendar year
50% of R&C after deductible for one physical exam each calendar year
Physical exams for children
(routine)
Covered at 100% (not subject to deductible)
Subject to Plan limits
60% of R&C after deductible
Subject to Plan limits
Covered at 100% (not subject to deductible)
Subject to Plan limits
50% of R&C after deductible
Subject to Plan limits
Physical therapy
80% after deductible. Medical Necessity Required.
60% of R&C after deductible. Medical Necessity Required.
70% after deductible. Medical Necessity Required.
50% of R&C after deductible. Medical Necessity Required.
Pregnancy termination
80% after deductible
60% of R&C after deductible
70% after deductible
50% of R&C after deductible
Prenatal visits
80% after deductible first visit onlyRoutine Prenatal Care covered at 100%
60% of R&C after deductible
70% after deductible first visit onlyRoutine Prenatal Care covered at 100%
50% of R&C after deductible
Private Duty Nursing
80% after deductible
Maximum of 60 visits (8-hour shifts) per calendar year
(Combined in-network/out-of-network)
Preauthorization is required
60% of R&C after deductible
Maximum of 60 visits (8-hour shifts) per calendar year
(Combined in-network/out-of-network)
Preauthorization is required
70% after deductible
Maximum of 60 visits (8-hour shifts) per calendar year
(Combined in-network/out-of-network)
Preauthorization is required
50% of R&C after deductible
Maximum of 60 visits (8-hour shifts) per calendar year
(Combined in-network/out-of-network)
Preauthorization is required
Prostate specific antigen test – PSA
(routine)
Covered at 100% (not subject to deductible)
60% of R&C after deductible
Covered at 100% (not subject to deductible)
50% of R&C after deductible
Prescription drugs
There is a pharmacy network for retail and mail order prescription drugs.
There is a pharmacy network for retail and mail order prescription drugs.
There is a pharmacy network for retail and mail order prescription drugs.
There is a pharmacy network for retail and mail order prescription drugs.
Skilled nursing facility
80% after deductible for up to 120 days per calendar year (combined in-network/out-of-network)
Preauthorization is required.
60% of R&C after deductible for up to 120 days per calendar year ) (combined in-network/out-of-network)
Preauthorization is required.
70% after deductible for up to 120 days per calendar year (combined in-network/out-of-network)
Preauthorization is required.
50% of R&C after deductible for 120 days per calendar year (combined in-network/out-of-network)
Preauthorization is required.
Speech therapy
80% after deductible. Medical Necessity Required.
60% of R&C after deductible. Medical Necessity Required.
70% after deductible. Medical Necessity Required.
50% of R&C after deductible. Medical Necessity Required.
Surgery
80% after deductible
Preauthorization is required if in-patient
Predetermination of benefits is recommended for multiple surgical procedures
60% of R&C after deductible
Preauthorization is required if in-patient
Predetermination of benefits is recommended for multiple surgical procedures
70% after deductible
Preauthorization is required if in-patient
Predetermination of benefits is recommended for multiple surgical procedures
50% of R&C after deductible
Preauthorization is required if in-patient
Predetermination of benefits is recommended for multiple surgical procedures
Tubal ligation
Covered at 100%, deductible does not apply
60% of R&C after deductible
Covered at 100%, deductible does not apply
50% of R&C after deductible
Urgent Care
80% after deductible
60% of R&C after deductible
70% after deductible
50% of R&C after deductible
Vasectomy
80% after deductible
60% of R&C after deductible
70% after deductible
50% of R&C after deductible
Virtual Medicine
80% after deductible
Not covered
70% after deductible
Not covered
Vision care
(routine eye care)
Not covered
Not covered
Not covered
Not covered
Vision Therapy/
Orthoptics
80% after deductible (maximum of 12 vision therapy visits or sessions medically necessary for treatment of convergence insufficiency)
60% of R&C after deductible (maximum of 12 vision therapy visits or sessions medically necessary for treatment of convergence insufficiency)
70% after deductible (maximum of 12 vision therapy visits or sessions medically necessary for treatment of convergence insufficiency)
50% of R&C after deductible (maximum of 12 vision therapy visits or sessions medically necessary for treatment of convergence insufficiency)
X-rays
80% after deductible
60% of R&C after deductible
70% after deductible
50% of R&C after deductible