BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
Infertility Services Coverage will be provided for the following services: Testing and treatment services performed in connection with an underlying medical condition. Testing performed specifically to determine the cause of infertility. Treatment and/or procedures performed specifically to restore fertility (e.g. procedures to correct an infertility condition). Surgical Treatment: Limited to procedures for the correction of infertility (excludes Artificial Insemination, In-vitro, GIFT, ZIFT, etc.) . Physician’s Office Visit (Lab and Radiology Tests, Counseling) 80% after plan deductible 50% after plan deductible
Inpatient Facility
80% after plan deductible
50% after plan deductible
Outpatient Facility
80% after plan deductible
50% after plan deductible
Physician’s Services
80% after plan deductible
50% after plan deductible
. Organ Transplants Includes all medically appropriate, non- experimental transplants Physician’s Office Visit
80% after plan deductible
In-Network coverage only
Inpatient Facility
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)
In-Network coverage only
Physician’s Services
In-Network coverage only
Lifetime Travel Maximum: $10,000 per transplant . Durable Medical Equipment Calendar Year Maximum: Unlimited . Breast Feeding Equipment and Supplies Note: Includes the rental of one breast pump per birth as ordered or prescribed by a physician. Includes related supplies.
In-Network coverage only
80% after plan deductible
50% after plan deductible
No charge
In-Network coverage only
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