Plan pays 100% (PA Plan pays 100%(PA Plan pays 100%(PA Plan pays 100% required) required) required) Blood & Blood Derivatives Plan pays 100% Plan pays 100% Plan pays 100% Plan pays 100% Breast Reconstructive Plan pays 100%(PA Plan pays 100%(PA Plan pays 100%(PA Surgery (In accordance with Not Covered required) required) required) 1998 W.H.C.R.A) Plan pays 100%. PA $75 copay, PA required for $75 copay, PA required for Cardiac Surgery Plan pays 100% required for off- services off-island services not off-island services not not available on Guam. available on Guam. available on Guam. Cataract Surgery Plan pays 100%. PA required for off-island Plan pays 100%(PA Plan pays 100%(PA Plan pays 100% services not available on required) required) Guam. Outpatient Only (including conventional lens) Plan pays 100%. Outpatient Plan pays 100%. Outpatient Plan pays 100%. Outpatient Plan pays 100%. Outpatient psychiatric and psychological psychiatric and psychological psychiatric and psychological psychiatric and psychological Chemical Dependency services to include counseling services to include counseling services to include counseling services to include counseling and medications. and medications. and medications. and medications. Chemotherapy Benefit Plan pays 100% Plan pays 100% Plan pays 100% Plan pays 100% Chiropractic Care
Plan pays 100% Plan pays 100% (PA required) Plan pays 100%(PA required) Plan pays 100%(PA required) Blood & Blood Derivatives Plan pays 100% Plan pays 100% Plan pays 100% Plan pays 100% Breast Reconstructive Surgery (In accordance with 1998 W.H.C.R.A) Not Covered Plan pays 100%(PA required) Plan pays 100%(PA required) Plan pays 100%(PA required) Cardiac Surgery Plan pays 100% Plan pays 100%. PA required for off- services not available on Guam. $75 copay, PA required for off-island services not available on Guam. $75 copay, PA required for off-island services not available on Guam. Cataract Surgery Plan pays 100% Plan pays 100%. PA required for off-island services not available on Guam. Plan pays 100%(PA required) Plan pays 100%(PA required) Outpatient Only (including conventional lens) Chemical Dependency Plan pays 100%. Outpatient psychiatric and psychological services to include counseling and medications. Plan pays 100%. Outpatient psychiatric and psychological services to include counseling and medications. Plan pays 100%. Outpatient psychiatric and psychological services to include counseling and medications. Plan pays 100%. Outpatient psychiatric and psychological services to include counseling and medications. Chemotherapy Benefit Plan pays 100% Plan pays 100% Plan pays 100% Plan pays 100% Chiropractic Care