BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
Men’s Family Planning Services Office Visits, Lab and Radiology Tests and Counseling Surgical Sterilization Procedures for Vasectomy (excludes reversals) Physician’s Office Visit
80% after plan deductible
50% of the Maximum Reimbursable Charge after plan deductible
80% after plan deductible
50% of the Maximum Reimbursable Charge after plan deductible 50% of the Maximum Reimbursable Charge after plan deductible 50% of the Maximum Reimbursable Charge after plan deductible 50% of the Maximum Reimbursable Charge after plan deductible
Inpatient Facility
80% after plan deductible
Outpatient Facility
80% after plan deductible
Physician’s Services
80% after plan deductible
Fertility Services Coverage is provided for the following services: • diagnosis of infertility and treatment of infertility once a condition of infertility has been diagnosed (excludes Artificial Insemination). Physician’s Office Visit (Lab and Radiology Tests, Counseling) 80% after plan deductible 50% of the Maximum Reimbursable Charge after plan deductible Inpatient Facility 80% after plan deductible 50% of the Maximum Reimbursable Charge after plan deductible Outpatient Facility 80% after plan deductible 50% of the Maximum Reimbursable Charge after plan deductible Physician’s Services 80% after plan deductible 50% of the Maximum Reimbursable Charge after plan deductible Transplant Services and Related Specialty Care Includes all medically appropriate, non- experimental transplants Physician’s Office Visit 80% after plan deductible In-Network coverage only Inpatient Facility In-Network coverage only
100% at LifeSOURCE center after plan deductible, otherwise 80% after plan deductible 100% at LifeSOURCE center after plan deductible, otherwise 80% after plan deductible No charge after plan deductible (only available when using LifeSOURCE facility)
Physician’s Services
In-Network coverage only
Lifetime Travel Maximum: $10,000 per transplant
In-Network coverage only
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