BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
External Prosthetic Appliances Calendar Year Maximum: Unlimited
80% after plan deductible
50% of the Maximum Reimbursable Charge after plan deductible
Hearing Aids Lifetime Maximum Amount: $1,000 Note: (Include Testing and fitting of hearing aid devices at Physician Office Visit cost share.)
80% after plan deductible
50% of the Maximum Reimbursable Charge after plan deductible
Wigs
Lifetime Maximum: $750
No charge after plan deductible
No charge of the Maximum Reimbursable Charge after plan deductible
Nutritional Counseling Calendar Year Maximum: 3 visits; the visit limit does not apply to treatment of diabetes and to mental health and substance use disorder conditions. Physician’s Office Visit
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
Genetic Counseling Calendar Year Maximum:
3 visits for counseling, pre- and post- genetic testing; however, the 3 visit limit will not apply to mental health and substance use disorder conditions. Physician’s Office Visit
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
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