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
No charge after the $30 PCP or $40 Specialist per office visit copay
50% of the Maximum Reimbursable Charge after plan deductible
No charge after the $30 PCP or $40 Specialist per office visit copay
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) No charge after the $30 PCP or $40 Specialist per office visit copay 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 No charge after the $30 PCP or $40 Specialist per office visit copay 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 (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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