Radiation Therapy Plan pays 100% Plan pays 100% $4.00 $4.00 (Pre-Certification Required) Robotic Surgery/Robotics Suite not covered not covered not covered not covered (Pre-Certification Required) Skilled Nursing Facility $75.00 copay, per day up $75.00 per day up to Plan pays 100%. Limited to to 10 days. No copay after 10 days. No copay after 10 Plan pays 100%. 60 days 180 days maximum per fiscal 10 days. PA required. 180 days. PA required. 180 max per fiscal year. year. days maximum per fiscal days maximum per fiscal year year (Pre-Certification Required) Sleep Apnea Diagnostics and Therapeutic Plan pays 100% (PA Plan pays 100% (PA Procedure $4.00 $4.00 copay required) required) (Pre-Certification Required) Sterilization Procedures (Tubal Ligation and Vasectomy) Vasectomy (Outpatient Plan pays 100% (PA Plan pays 100% (PA $4.00 copay, no PA $4.00 copay, no PA Only) required) required) required. required.
Radiation Therapy Plan pays 100% Plan pays 100% $4.00 $4.00 (Pre-Certification Required) Robotic Surgery/Robotics Suite not covered not covered not covered not covered (Pre-Certification Required) Skilled Nursing Facility Plan pays 100%. Limited to 180 days maximum per fiscal year. Plan pays 100%. 60 days max per fiscal year. $75.00 copay, per day up to 10 days. No copay after 10 days. PA required. 180 days maximum per fiscal year $75.00 per day up to 10 days. No copay after 10 days. PA required. 180 days maximum per fiscal year (Pre-Certification Required) Sleep Apnea Plan pays 100% (PA required) Plan pays 100% (PA required) $4.00 $4.00 copay Diagnostics and Therapeutic Procedure (Pre-Certification Required) Sterilization Procedures (Tubal Ligation and Vasectomy) Vasectomy (Outpatient Only) Plan pays 100% (PA required) Plan pays 100% (PA required) $4.00 copay, no PA required. $4.00 copay, no PA required.
Bill%20No.%20132-34%20(COR).docx