Page 19 - QCS.19 SPD - HSA

Covered Health Care Service Network Out-of-Network

Hearing Aids
Note: For enrolled Dependent
deductible then 100% deductible then 50%
children under the age of 18:
One hearing aid, per hearing
impaired ear every 36 months.
Note: Age 18 and over:
Limited to $5,000 in Allowed
Amounts per Covered Person
every 36 months.

Home Health Care
Limited to 30 visits per Calendar deductible then 100% deductible then 50%
Year. One visit equals up to four
hours of skilled care services.
Hospice Care

Inpatient Stay deductible then 100% deductible then 50%
Outpatient deductible then 100% deductible then 50%

Hospital - Inpatient Stay
deductible then 100% deductible then 50%

Lab, X-Ray and Diagnostic
Physician deductible then 100% deductible then 50%

Limited to 18 Presumptive Drug Tests per year.
Limited to 18 Definitive Drug Tests per year.

Facility deductible then 100% deductible then 50%

Note: This benefit does not include
Lab, X-Ray, and other diagnostics
performed as part of Emergency
Health Care Services.

Major Diagnostic and Imaging
Physician deductible then 100% deductible then 50%

Facility deductible then 100% deductible then 50%

Maternity Services
Depending upon where the Depending upon where the
Note: A Deductible will not apply for Covered Health Care Service is Covered Health Care Service is
a newborn child with a length of stay provided, Benefits will be the same provided, Benefits will be the same
in the Hospital the same as the as those stated under each as those stated under each
mother's length of stay and their Covered Health Care Service Covered Health Care Service
billed services are included with the category in this Schedule of category in this Schedule of
mother's stay. Benefits. Benefits.

Page 14 Section 4 - Schedule of Benefits
HSA - 2017