special situations (e.g., trauma, brain injury) for additional visits. COMMON AND PREVENTIVE SERVICES Physician Office Visits - 100% after $15 80% of allowed Primary Care copay benefit after deductible Physician Office Visits 100% after $25 80% of allowed – Specialist copay benefit deductible Preventive Health Office 100% of allowed 80% of allowed Visit and Associated Lab benefit benefit after (Adult and Child) deductible Routine annual GYN 100% of allowed 80% of allowed Exam (including PAP benefit benefit after test) deductible Hearing Examinations 100% after $15 80% of allowed and Hearing Aids copay PCP or $25 benefit after – copay Specialist deductible – 100% of allowed 80% of allowed benefit for benefit Model Hearing Aid deductible for Basic Model Hearing Aid A model hearing aid is a hearing aid worn on the exterior of the ear and is used primarily for hearing amplification. It does not include implant devices. The basic model hearing aid will not require prior authorization. Limited to once every No deviations will be considered. three years per ear. Includes Maryland mandated benefit for hearing aids for children (ages 0-18), including hearing aids per each impaired ear for minor children. Immunizations 100% of allowed 80% of allowed benefit benefit after deductible Immunizations are only covered as recommended by the U.S. Preventive Services Task Force. The immunization benefit covers immunizations required No deviations will be considered. for participation in school athletics and Lyme Disease immunizations when medically necessary. 80% of allowed 100% of Allowed benefit after Flu Shots Benefit deductible Mammography 80% of allowed 100% of allowed Preventive benefit benefit deductible
special situations (e.g., trauma, brain injury) for additional visits. COMMON AND PREVENTIVE SERVICES Physician Office Visits - Primary Care 100% after $15 copay 80% of allowed benefit after deductible Physician Office Visits – Specialist 100% after $25 copay 80% of allowed benefit deductible Preventive Health Office Visit and Associated Lab (Adult and Child) 100% of allowed benefit 80% of allowed benefit after deductible Routine annual GYN Exam (including PAP test) 100% of allowed benefit 80% of allowed benefit after deductible Hearing Examinations and Hearing Aids 100% after $15 copay – PCP or $25 copay – Specialist 80% of allowed benefit after deductible 100% of allowed benefit for Model Hearing Aid 80% of allowed benefit deductible for Basic Model Hearing Aid A model hearing aid is a hearing aid worn on the exterior of the ear and is used primarily for hearing amplification. It does not include implant devices. The basic model hearing aid will not require prior authorization. Limited to once every three years per ear. Includes Maryland mandated benefit for hearing aids for children (ages 0-18), including hearing aids per each impaired ear for minor children. No deviations will be considered. Immunizations 100% of allowed benefit 80% of allowed benefit after deductible Immunizations are only covered as recommended by the U.S. Preventive Services Task Force. The immunization benefit covers immunizations required for participation in school athletics and Lyme Disease immunizations when medically necessary. No deviations will be considered. Flu Shots 100% of Allowed Benefit 80% of allowed benefit after deductible Mammography Preventive 100% of allowed benefit 80% of allowed benefit deductible
SLEOLAMedical_FA1_PPO-SF.docx