Page 38 - University of the South-2022-Benefit Guide REVISED 3.30.22 FSA WAIT PERIOD

What You Will Pay
Common Out-of-Network Limitations, Exceptions, & Other Important
Medical Event Services You May Need In-Network Provider Provider Information
(You will pay the least) (You will pay the most)
Facility fee (e.g., hospital Prior Authorization required. Your cost share
If you have a room) 20% coinsurance 40% coinsurance may increase to 50% if not obtained.
hospital stay Prior Authorization required. Your cost share
Physician/surgeon fees 20% coinsurance 40% coinsurance
may increase to 50% if not obtained.
$25 copay/visit
If you need mental deductible does not Prior Authorization required for electro-
health, behavioral Outpatient servsices apply for office visits 40% coinsurance convulsive therapy (ECT). Your cost share
health, or and 20% coinsurance may increase to 50% if not obtained.
substance abuse other outpatient services
services Prior Authorization required. Your cost share
Inpatient services 20% coinsurance 40% coinsurance
may increase to 50% if not obtained.
$25 copay/visit
Office visits deductible does not 40% coinsurance PhysicianNow - Powered by MDLIVE: $15
copay
apply.
This service may be covered under the
Childbirth/delivery 20% coinsurance 40% coinsurance Specialty Care Program. Cost Share may
If you are pregnant professional services vary; use a Blue Distinction Center for best
benefit.
This service may be covered under the
Childbirth/delivery facility Specialty Care Program. Cost Share may
services 20% coinsurance 40% coinsurance vary; use a Blue Distinction Center for best
benefit.
Home health care No Charge 40% coinsurance Unlimited.
Therapy limited to 30 visits per type per year.
Rehabilitation services 20% coinsurance 40% coinsurance Cardiac/Pulmonary rehab limited to 36 visits
per type per year.
Therapy limited to 30 visits per type per year.
Habilitation services 20% coinsurance 40% coinsurance Cardiac/Pulmonary rehab limited to 36 visits
If you need help per type per year.
recovering or have
other special Skilled nursing care 20% coinsurance 40% coinsurance Skilled nursing and rehabilitation facility
health needs limited to 100 days combined per year.
Durable medical 20% coinsurance 40% coinsurance Prior Authorization may be required for
certain durable medical equipment. Your cost
equipment
share may increase to 50% if not obtained.
Prior Authorization required for inpatient
Hospice services No Charge 40% coinsurance hospice. Your cost share may increase to
50% if not obtained.
Children’s eye exam Not Covered Not Covered None
If your child needs Children’s glasses Not Covered Not Covered None
dental or eye care Children’s dental check- Not Covered Not Covered None
up
Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Bariatric surgery • Infertility treatment • Routine eye care (Adult)
• Cosmetic surgery • Long-term care • Routine eye care (Children)
• Dental care (Adult) • Non-emergency care when traveling outside the • Routine foot care for non-diabetics
• Dental care (Children) U.S. • Weight loss programs
• Hearing aids for adults • Private-duty nursing

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Acupuncture • Hearing aids for children under 18 • Chiropractic care

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