BENEFIT HIGHLIGHTS
IN-NETWORK
OUT-OF-NETWORK
External Prosthetic Appliances Calendar Year Maximum: Unlimited . Nutritional Evaluation Calendar Year Maximum:
80% after plan deductible
50% after plan deductible
3 visits per person however, the 3 visit limit will not apply to treatment of mental health and substance use disorder conditions.
Physician’s Office Visit
No charge after the $30 PCP or $40 Specialist per office visit copay
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
Genetic Counseling
Calendar Year Maximum: 3 visits per person for Genetic
Counseling for both pre- and post- genetic testing; however, the 3 visit limit will not apply to Mental Health and Substance Use Disorder conditions. Physician’s Office Visit
No charge after the $30 PCP or $40 Specialist per office visit copay
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 . Dental Care Limited to charges made for a
80% after plan deductible
50% after plan deductible
continuous course of dental treatment started within six months of an injury to teeth. Physician’s Office Visit
No charge after the $30 PCP or $40 Specialist per office visit copay
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
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