Laserfiche WebLink
Your Summary of Benefits <br />Behavioral Health Services <br />Mental Illness and Substance Abusez: <br />7o-�-w7l)% <br />o Inpatient Facility Services <br />o Inpatient Professional Services <br />20% <br />o Physician Home and Office Visits (PCP/SCP) <br />$30$30 <br />o Other Outpatient Services, Outpatient Facility <br />20% <br />@ Hospital/Alternative Care Facility, <br />Outpatient Professional <br />Human Organ and Tissue Transplants3 <br />NCS <br />50%- <br />o Acquisition and transplant procedures, <br />harvest and storacge® <br />Prescription Drug Options: <br />Anthem National Drug List <br />Network Tier structure equals 11213 <br />(and 4, if applicable) <br />Tier 1: 20% <br />50%, min $604 <br />o Network Retail Pharmacies: <br />Tier 2: 30% <br />(30-day supply) <br />Tier 3: 40% <br />Includes diabetic test strip <br />All Tiers: $250 maximum per <br />prescription <br />o Home Delivery Service: <br />Tier 1: 20% <br />Not covered <br />(90-day supply) <br />Tier 2: 30% <br />Includes diabetic test strip <br />Tier 3: 40% <br />All Tiers: $750 maximum per <br />prescription <br />$2,600/$5,200 <br />$5,200/$10,400 <br />o Calendar Year Out of Pocket Maximum: <br />Member may be responsible for additional cost when not <br />selecting the available generic drug. <br />Medicare Rx • Wrap <br />Lifetime Maximum <br />Medical <br />Unlimited <br />Unlimited <br />Surgical Treatment of Morbid Obesity <br />Not covered <br />Not covered <br />iwwa. <br />o All medical and prescription drug deductibles, copayments and coinsurance apply toward the out-of-pocket maximum (excluding Non -Network <br />Human Organ and Tissue Transplant (HOTT) Services) <br />o Deductible(s) apply to covered medical services listed with a percentage (%) coinsurance, including 0%. However, the deductible does not apply <br />to Emergency Room Services where a copayment and coinsurance applies and may not apply to some Behavioral Health services where <br />coinsurance applies. <br />o Dependent age: to end of the month which the child attains age 26. <br />o Specialist copayment is applicable to all Specialists excluding General Physicians, Internist, Pediatricians, OB/GYNs and Geriatrics or any other <br />Network Provider as allowed by the plan. <br />o Ambulance Non -network non -emergency use limited to $50,000 per benefit period. <br />o NCS (No Cost Share) means no deductible/copayment/coinsurance up to the maximum allowable amount. <br />