Agreement - Blue Cross Blue Shield - Self Fund Medical Insurance for CIty Employees for 2019

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Your ummary of Benefits 4 tl 81411 4 Other Outpatient Services 20% 50% including but not limited to: o Non Surgical Outpatient Services For example: MRIs, C-Scans, Chemotherapy, Ultrasounds and other diagnostic outpatient services, o Home Care Services 90 visits (excludes IV Therapy) (Network/Non-network combined) o Durable Medical Equipment, Orthotics and Prosthetics o Physical Medicine Therapy Day Rehabilitation programs o Hospice Care 20% 20% o Ambulance Services __. 20% 20% __. _ .....m.. Accidental Dental Services $3,000 per accident n ......... 20% 50% (Network and Non -network combined Outpatient Therapy Services (Combined Network & Non -Network limits apply) o Physician Home and Office Visits 20% 50% o Other Outpatient Services @ Hospital/Alternative 20% 50% Care Facility Limits apply to: o Cardiac Rehabilitation: Unlimited o Pulmonary Rehabilitation: Unlimited o Physical therapy: 60 visits o Occupational therapy: 60 visits o Manipulation therapy: 12 visits o Speech therapy: 40 visits Behavioral Health Services: Benefits provided in 50% Mental Illness and Substance Abuse' accordance with Federal o Inpatient Facility Services Mental Health Parity o Physician Home and Office Visits o Other Outpatient Services @ Hospital/Alternative Care Facility Human Organ and Tissue Transplants o Acquisition and transplant procedures, 20% 50% harvest and storage.