25% Must be enrolled in Obesity Management Take (Prior authorization 35% Control for recommended by all plans) surgical treatment 25% TMJ Surgical 35% (Prior authorization recommended) treatment only Transplants Transplant Services 25% 35% (Prior authorization required) Travel 0% 0% up to $1,500/year up to $1,500/year with with Travel for patient only Prior authorization Prior authorization (If services are not available in -up to $5,000/yr. in -up to $5,000/yr. in conjunction with conjunction with community) transplants transplants only with Prior only with Prior authorization authorization Discover Great Health! Preventive Health Screenings/ Healthy Lifestyle Ed. & Support/ see page 15 Emotional & Financial Wellness Take Control Tobacco Cessation, Diabetes, Weight Loss, High Cholesterol, High see page 16 Pressure WellBaby Infusion Therapy Incentive Program see page 17 Reminder: Deductible applies to all covered services unless otherwise indicated or a copay applies. Out-of-Network providers can balance bill the difference between their charge and the allowed amount. - 13-
Obesity Management (Prior authorization recommended by all plans) 25% Must be enrolled in Take Control for treatment 35% TMJ (Prior authorization recommended) 25% Surgical treatment only 35% Transplants Transplant Services (Prior authorization required) 25% 35% Travel Travel for patient only (If services are not available in community) 0% up to $1,500/year with Prior authorization -up to $5,000/yr. in conjunction with transplants only with Prior authorization 0% up to $1,500/year with Prior authorization -up to $5,000/yr. in conjunction with transplants only with Prior authorization Discover Great Health! Preventive Health Screenings/ Healthy Lifestyle Ed. & Support/ Emotional & Financial Wellness see page 15 Take Control see page 16 Tobacco Cessation, Diabetes, Weight Loss, High Cholesterol, High Pressure WellBaby Infusion Therapy Incentive Program see page 17 Reminder: Deductible applies to all covered services unless otherwise indicated or a copay applies. Out-of-Network providers can balance bill the difference between their charge and the allowed amount. - 13- surgical
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