Ambulance Services – 100% of allowed 80% of allowed Non-Emergency benefit benefit Transport MATERNITY BENEFITS 80% of allowed 100% of allowed Maternity Benefits benefit after benefit deductible Prenatal Care 100% of allowed 80% of allowed benefit benefit after deductible Newborn Care 100% of allowed 80% of allowed benefit benefit after deductible Breastfeeding Support 100% of allowed 80% of allowed and Counseling benefit benefit after deductible Breastfeeding Supplies 100% of allowed Not Covered (per birth) benefit Covers the cost of rental/purchase of certain breastfeeding equipment pumps No deviations will be considered. through Carrier’s DME partner(s). SERVICES AND SUPPLIES Acupuncture Services for 100% after $20 80% of allowed Chronic Pain copay benefit after Management deductible Chiropractic Services 100% after $20 80% of allowed copay benefit after deductible Cardiac Rehabilitation 100% of allowed 80% of allowed benefit benefit after deductible Dental Services Not covered except as a result of accident or injury or as mandated by No deviations will be considered. Maryland or federal law. Nutritional Counseling 100% of allowed 80% of allowed benefit benefit after deductible 100% of allowed 80% of allowed benefit benefit after Durable Medical deductible Equipment Must be medically necessary as No deviations will be considered. determined by the attending physician Extended Care Facilities 100% of allowed 80% of allowed benefit benefit deductible Skilled nursing care and extended care facility benefits are limited to 180 days No deviations will be considered. per calendar year as long as skilled nursing care is medically necessary.
Ambulance Services – Non-Emergency Transport 100% of allowed benefit 80% of allowed benefit MATERNITY BENEFITS Maternity Benefits 100% of allowed benefit 80% of allowed benefit after deductible Prenatal Care 100% of allowed benefit 80% of allowed benefit after deductible Newborn Care 100% of allowed benefit 80% of allowed benefit after deductible Breastfeeding Support and Counseling 100% of allowed benefit 80% of allowed benefit after deductible Breastfeeding Supplies (per birth) 100% of allowed benefit Not Covered Covers the cost of rental/purchase of certain breastfeeding equipment pumps through Carrier’s DME partner(s). No deviations will be considered. SERVICES AND SUPPLIES Acupuncture Services for Chronic Pain Management 100% after $20 copay 80% of allowed benefit after deductible Chiropractic Services 100% after $20 copay 80% of allowed benefit after deductible Cardiac Rehabilitation 100% of allowed benefit 80% of allowed benefit after deductible Dental Services Not covered except as a result of accident or injury or as mandated by Maryland or federal law. No deviations will be considered. Nutritional Counseling 100% of allowed benefit 80% of allowed benefit after deductible Durable Medical Equipment 100% of allowed benefit 80% of allowed benefit after deductible Must be medically necessary as determined by the attending physician No deviations will be considered. Extended Care Facilities 100% of allowed benefit 80% of allowed benefit deductible Skilled nursing care and extended care facility benefits are limited to 180 days per calendar year as long as skilled nursing care is medically necessary. No deviations will be considered.
SLEOLAMedical_FA3_POS-SF.docx