Screening: One each year 35+ No deviations will be considered. Mammography 80% of allowed 100% of allowed Diagnostic benefit after benefit deductible No age/frequency limitation on No deviations will be considered. diagnostic mammogram. Physical Exams 100% of allowed 80% of allowed benefit benefit after deductible One exam per plan year for all members and their dependents age three (3) and No deviations will be considered. older. Well Baby Care 100% of allowed 80% of allowed benefit benefit after deductible Birth 3036 months: 13 visits total No deviations will be considered. – STI Screening and 100% of allowed 80% of allowed Counseling (Including benefit benefit after HPV DNA and HIV) deductible Counseling and screening for sexually No deviations will be considered. active women as mandated by PPACA. Allergy Testing 100% $15 80% of allowed copay PCP; $25 benefit after – copay Specialist deductible – EMERGENCY TREATMENT 80% of allowed Urgent Care Office Visit $20 copay benefit after deductible Emergency Room (ER) 100% of allowed 100% of allowed Services and Out of benefit $50 benefit after $50 –In Network facility copay and facility copay and $50 physician $50 physician 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 $50 copays. Observation up to 23 100% of allowed 80% of allowed – hours and 59 minutes - benefit $50 benefit after presented via facility copay and deductible Emergency Department $50 physician copay Observation 24 hours 100% of allowed 80% of allowed – or more - presented via benefit benefit after Emergency Department deductible Ambulance Services 100% of allowed 100% of allowed – Emergency Transport benefit benefit
Screening: One each year 35+ No deviations will be considered. Mammography Diagnostic 100% of allowed benefit 80% of allowed benefit after deductible No age/frequency limitation on diagnostic mammogram. No deviations will be considered. Physical Exams 100% of allowed benefit 80% of allowed benefit after deductible One exam per plan year for all members and their dependents age three (3) and older. No deviations will be considered. Well Baby Care 100% of allowed benefit 80% of allowed benefit after deductible Birth – 3036 months: 13 visits total No deviations will be considered. STI Screening and Counseling (Including HPV DNA and HIV) 100% of allowed benefit 80% of allowed benefit after deductible Counseling and screening for sexually active women as mandated by PPACA. No deviations will be considered. Allergy Testing 100% $15 copay – PCP; $25 copay – Specialist 80% of allowed benefit after deductible EMERGENCY TREATMENT Urgent Care Office Visit $20 copay 80% of allowed benefit after deductible Emergency Room (ER) Services –In and Out of Network 100% of allowed benefit $50 facility copay and $50 physician copay 100% of allowed benefit after $50 facility copay and $50 physician 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 $50 copays. Observation – up to 23 hours and 59 minutes - presented via Emergency Department 100% of allowed benefit $50 facility copay and $50 physician copay 80% of allowed benefit after deductible Observation – 24 hours or more - presented via Emergency Department 100% of allowed benefit 80% of allowed benefit after deductible Ambulance Services – Emergency Transport 100% of allowed benefit 100% of allowed benefit
SLEOLAMedical_FA3_POS-SF.docx