What You Pay for Services
Copays ($) and Coinsurance (%) for Covered Health Care Services
Out-of-Network
Network
Enteral Nutrition
No copay*
50%*
Hearing Aids
No copay*
50%*
Limited to $5,000 every 36 months. Benefits are further limited to a single purchase per hearing impaired ear including repair or replacement. For enrolled Dependent children under the age of 18: One hearing aid, per hearing impaired ear every 36 months.
Ostomy Supplies
No copay*
50%*
Pharmaceutical Products - Outpatient
No copay*
50%*
Depending on the pharmaceutical product prior authorization may be required. This includes medications given at a doctor's office, or in a covered person's home.
Prosthetic Devices¹
No copay*
50%*
Pregnancy
Pregnancy - Maternity Services¹
The amount you pay is based on where the covered health care service is provided except that an Annual Deductible will not apply for a newborn child whose length of stay in the Hospital is the same as the mother's length of stay.
Mental Health Care & Substance Related and Addictive Disorder Services
Inpatient
No copay*
50%*
Outpatient
$75 copay
50%*
Partial Hospitalization
No copay*
50%*
Limited to 60 days combined for residential treatment facility and skilled nursing facility per year. Other Services
Cellular and Gene Therapy
The amount you pay is based on where the covered health care service is provided.
For Network Benefits, Cellular or Gene Therapy services must be received from a Designated Provider.
Clinical Trials¹
The amount you pay is based on where the covered health care service is provided.
Gender Dysphoria¹
The amount you pay is based on where the covered health care service is provided or in the Prescription Drug Benefits Section.
Hospice Care¹
No copay*
50%*
Reconstructive Procedures¹
The amount you pay is based on where the covered health care service is provided.
Transplantation Services
No copay*
Not covered
Coverage is only available when services are performed at a Centers of Excellence facility, except for cornea transplants.
*After the Annual Medical Deductible has been met. ¹Prior Authorization Required. Refer to SPD.
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