ARE REFERRALS REQUIRED IN THIS No referrals in this plan No deviations will be considered. PLAN? MANDATED BENEFITS All mandated benefits, unless otherwise No deviations will be considered. directed by the State. HOSPITAL INPATIENT SERVICES (Preauthorization Required) Inpatient Care 90% of allowed 70% of allowed benefit benefit after deducible Hospitalization 90% of allowed 70% of allowed benefit benefit after deductible Acute Inpatient Rehab 90% of allowed Not covered for Stroke and Traumatic benefit Brain Injury Patients when Medically Necessary Anesthesia* 90% of allowed 70% of allowed benefit benefit after deductible Surgery 90% of allowed 70% of allowed benefit benefit after deducible Acute Inpatient Rehab 90% of allowed Not covered (pre-cert required, must benefit be medically necessary) Organ Transplant 90% of allowed 70% of allowed benefit benefit after deductible HOSPITAL OUTPATIENT SERVICES (Preauthorization Required) Chemotherapy/ 90% of allowed 70% of allowed Radiation benefit benefit after deductible Diagnostic Lab Work and 100% of allowed 70% of allowed X-rays** benefit benefit after deductible Outpatient surgery 90% of allowed 70% of allowed benefit benefit after deductible Anesthesia* 90% of allowed 70% of allowed benefit benefit after deductible Observation – up to 23 100% of allowed 70% of allowed hours and 59 minutes - benefit after $75 benefit after presented via facility copay and deductible Emergency Department $75 physician copay Observation – 24 hours 90% of allowed 70% of allowed
ARE REFERRALS REQUIRED IN THIS PLAN? No referrals in this plan No deviations will be considered. MANDATED BENEFITS All mandated benefits, unless otherwise directed by the State. No deviations will be considered. HOSPITAL INPATIENT SERVICES (Preauthorization Required) Inpatient Care 90% of allowed benefit 70% of allowed benefit after deducible Hospitalization 90% of allowed benefit 70% of allowed benefit after deductible Acute Inpatient Rehab for Stroke and Traumatic Brain Injury Patients when Medically Necessary 90% of allowed benefit Not covered Anesthesia* 90% of allowed benefit 70% of allowed benefit after deductible Surgery 90% of allowed benefit 70% of allowed benefit after deducible Acute Inpatient Rehab (pre-cert required, must be medically necessary) 90% of allowed benefit Not covered Organ Transplant 90% of allowed benefit 70% of allowed benefit after deductible HOSPITAL OUTPATIENT SERVICES (Preauthorization Required) Chemotherapy/ Radiation 90% of allowed benefit 70% of allowed benefit after deductible Diagnostic Lab Work and X-rays** 100% of allowed benefit 70% of allowed benefit after deductible Outpatient surgery 90% of allowed benefit 70% of allowed benefit after deductible Anesthesia* 90% of allowed benefit 70% of allowed benefit after deductible Observation – up to 23 hours and 59 minutes - presented via Emergency Department 100% of allowed benefit after $75 facility copay and $75 physician copay 70% of allowed benefit after deductible Observation – 24 hours 90% of allowed 70% of allowed
F10B3400022-AttachmentS-PPO-SF.docx