BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
Obesity/Bariatric Surgery Note: Coverage is provided subject to medical necessity and clinical guidelines subject to any limitations shown in the “Exclusions, Expenses Not Covered and General Limitations” section of this certificate. Physician’s Office Visit
No charge after the $30 PCP or $40 Specialist per office visit copay
In-Network coverage only
Inpatient Facility Outpatient Facility
80% after plan deductible 80% after plan deductible
In-Network coverage only In-Network coverage only
Physician’s Services
80% after plan deductible
In-Network coverage only
Surgical Professional Services Lifetime Maximum: $20,000 Notes: • Includes charges for surgeon only; does not include radiologist, anesthesiologist, etc. • Accumulates to the Out-of-Pocket Maximum. • Only surgical services accumulate to the maximum.
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