Page 21 - QCS.19 SPD - HSA

Covered Health Care Service Network Out-of-Network

Skilled Nursing Facility/Inpatient Rehabilitation Facility Services
Limited to 60 days per
Calendar Year combined with deductible then 100% deductible then 50%
Residential Treatment Facility limit.

Surgery - Outpatient Facility
deductible then 100% deductible then 50%

Therapeutic Treatments
deductible then 100% deductible then 50%

Transplantation Services
For Network Benefits, deductible then 100% Not covered
transplantation services must be
received at a Designated Facility.
We do not require that cornea
transplants be performed at a
Designated Facility in order for you
to receive Network Benefits.
Note: The transplant network is
different than the plan provider
Network. Any transplant services
outside of the Designated Facilities,
including PPO providers and
facilities, are considered out-of-
network and NOT covered under the
plan. To ensure Network Benefits,
you must notify us as soon as
possibility of a transplant arises and
before pre-transplantation
evaluation.

Note: Travel Expenses for a
transplant are limited to $5,000 per
transplant.

Urgent Care Center Services
Physician deductible then $100 Copayment** deductible then 50%
then 100%
Facility deductible then $100 Copayment** deductible then 50%
then 100%

*For the above services this means only one Copayment will apply for all covered services rendered by the same
provider during the same visit, confinement or occurrence.
**For the above services this means only one Copayment will apply for all covered services rendered during the
same visit or occurrence.
***Emergency ground and air ambulance by an Out-of-Network provider will be considered at the Network benefit
level.

Page 16 Section 4 - Schedule of Benefits
HSA - 2017