rehabilitation is not covered. Family Planning and 90% of allowed 70% of allowed Fertility Testing6 benefit benefit after deductible Contraception and 100% of allowed Not Covered Contraceptive benefit Counseling In-Vitro Fertilization 90% of allowed 70% of allowed (IVF) and Artificial benefit benefit after Insemination deductible (per MD mandate) IVF and AI benefits are limited to 3 attempts of Artificial Insemination, and 3 attempts of IVF per live birth. Not No deviations will be considered. covered following reversal of elective sterilization. Hospice Care 90% of allowed 70% of allowed benefit benefit after deductible Home Healthcare 90% of allowed 70% of allowed benefit benefit after deductible Home Healthcare benefits are limited to No deviations will be considered. 120 days per plan year Medical Supplies 90% of allowed 70% of allowed benefit benefit after deductible Includes, but is not limited to: surgical dressings; casts; splints; syringes; dressings for cancer, burns or diabetic ulcers; catheters; colostomy bags; No deviations will be considered. oxygen; supplies for renal dialysis equipment and machines; and all diabetic supplies as mandated by Maryland law. MENTAL HEALTH AND CHEMICAL DEPENDENCY SERVICES Inpatient Hospital Care 90% of allowed 70% of allowed benefit benefit after deductible Partial Hospitalization 90% of allowed 70% of allowed Services benefit benefit after No deviations will be considered. deductible Outpatient Services 70% of allowed 100% after $15 (Including Intensive benefit after copay Outpatient Services) deductible Residential Crisis 90% of allowed 70% of allowed Services benefit benefit after deductible
rehabilitation is not covered. Family Planning and Fertility Testing6 90% of allowed benefit 70% of allowed benefit after deductible Contraception and Contraceptive Counseling 100% of allowed benefit Not Covered In-Vitro Fertilization (IVF) and Artificial Insemination (per MD mandate) 90% of allowed benefit 70% of allowed benefit after deductible IVF and AI benefits are limited to 3 attempts of Artificial Insemination, and 3 attempts of IVF per live birth. Not covered following reversal of elective sterilization. No deviations will be considered. Hospice Care 90% of allowed benefit 70% of allowed benefit after deductible Home Healthcare 90% of allowed benefit 70% of allowed benefit after deductible Home Healthcare benefits are limited to 120 days per plan year No deviations will be considered. Medical Supplies 90% of allowed benefit 70% of allowed benefit after deductible Includes, but is not limited to: surgical dressings; casts; splints; syringes; dressings for cancer, burns or diabetic ulcers; catheters; colostomy bags; oxygen; supplies for renal dialysis equipment and machines; and all diabetic supplies as mandated by Maryland law. No deviations will be considered. MENTAL HEALTH AND CHEMICAL DEPENDENCY SERVICES Inpatient Hospital Care 90% of allowed benefit 70% of allowed benefit after deductible No deviations will be considered. Partial Hospitalization Services 90% of allowed benefit 70% of allowed benefit after deductible Outpatient Services (Including Intensive Outpatient Services) 100% after $15 copay 70% of allowed benefit after deductible Residential Crisis Services 90% of allowed benefit 70% of allowed benefit after deductible
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