BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
80% after plan deductible
50% after plan deductible
Hearing Aids
Lifetime Maximum: $1,000
No charge after plan deductible
No charge after plan deductible
Wigs
Lifetime Maximum Amount: $750
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
80% after plan deductible
In-Network coverage only
Inpatient Facility
80% after plan deductible
In-Network coverage only
Outpatient Facility
80% after plan deductible
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.
Not covered except for services associated with foot care for diabetes and peripheral vascular disease when Medically Necessary.
Not covered except for services associated with foot care for diabetes and peripheral vascular disease when Medically Necessary.
Routine Foot Disorders
Treatment Resulting From Life Threatening Emergencies Medical treatment required as a result of an emergency, such as a suicide attempt, will be considered a medical expense until the medical condition is stabilized. Once the medical condition is stabilized, whether the treatment will be characterized as either a medical expense or a mental health/substance use disorder expense will be determined by the utilization review Physician in accordance with the applicable mixed services claim guidelines.
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