medically necessary. Flu Shots 100% of Allowed Not covered No deviations will be considered. Benefit Mammography 70% of allowed 100% of allowed Preventive benefit after benefit deductible Screening: one mammogram per plan No deviations will be considered. year (35+). Mammography 70% of allowed 90% of allowed Diagnostic benefit after benefit deductible No age/frequency limitation on No deviations will be considered. diagnostic mammogram. Physical Exams 100% of allowed 70% of allowed benefit benefit after deductible One exam per plan year for all members No deviations will be considered. and their dependents age 3 and older. Well Baby Care 100% of allowed 70% of allowed benefit benefit after deductible Birth – 36 months: 12 visits total No deviations will be considered. STI Screening and 100% of allowed Not Covered Counseling (Including benefit HPV DNA and HIV) Counseling and screening for sexually No deviations will be considered. active women as mandated by PPACA. Norplant Surgery Only 90% of allowed 70% of allowed benefit benefit after deductible Allergy Testing 100% after $15 70% of allowed copay – PCP; $30 benefit after copay – Specialist deductible EMERGENCY TREATMENT Ambulance Services – 100% of allowed 100% of allowed Emergency Transport benefit benefit Ambulance Services – 90% of allowed 70% of allowed Non-Emergency benefit benefit Transport Emergency Room (ER) 100% of allowed Services –In and Out of benefit after $75 100% of allowed Network facility copay and benefit after $150 $75 physician combined copay copay Copays are waived if admitted. No deviations will be considered. If criteria are not met for a medical emergency, plan coverage is 50% of allowed amount, plus the two $75 copays.
medically necessary. Flu Shots 100% of Allowed Benefit Not covered No deviations will be considered. Mammography Preventive 100% of allowed benefit 70% of allowed benefit after deductible Screening: one mammogram per plan year (35+). No deviations will be considered. Mammography Diagnostic 90% of allowed benefit 70% of allowed benefit after deductible No age/frequency limitation on diagnostic mammogram. No deviations will be considered. Physical Exams 100% of allowed benefit 70% of allowed benefit after deductible One exam per plan year for all members and their dependents age 3 and older. No deviations will be considered. Well Baby Care 100% of allowed benefit 70% of allowed benefit after deductible Birth – 36 months: 12 visits total No deviations will be considered. STI Screening and Counseling (Including HPV DNA and HIV) 100% of allowed benefit Not Covered Counseling and screening for sexually active women as mandated by PPACA. No deviations will be considered. Norplant Surgery Only 90% of allowed benefit 70% of allowed benefit after deductible Allergy Testing 100% after $15 copay – PCP; $30 copay – Specialist 70% of allowed benefit after deductible EMERGENCY TREATMENT Ambulance Services – Emergency Transport 100% of allowed benefit 100% of allowed benefit Ambulance Services – Non-Emergency Transport 90% of allowed benefit 70% of allowed benefit Emergency Room (ER) Services –In and Out of Network 100% of allowed benefit after $75 facility copay and $75 physician copay 100% of allowed benefit after $150 combined copay Copays are waived if admitted. No deviations will be considered. If criteria are not met for a medical emergency, plan coverage is 50% of allowed amount, plus the two $75 copays.
F10B3400022-AttachmentS-PPO-SF.docx