Page 17 - PWH.19 Employee Benefits
P. 17
What You Will Pay Limitations, Exceptions, & Other
vider Non-Network Provider
least) (You will pay the most) Important Information
ce 30% coinsurance programs) are limited to 60 days of
care regardless of the provider's
Office Visit network status.
ce 30% coinsurance --------none--------
ent Other Outpatient
ce 30% coinsurance Office Visit
30 visits/benefit period for In-
ce 30% coinsurance Network Providers. 10 visits/benefit
period for Non-Network Providers.
ce 30% coinsurance Outpatient and Office services count
ce 30% coinsurance towards the limit. Costs may vary by
ce 30% coinsurance site of service. Alcoholism outpatient
(non-network) limited to 10 visits.
Other Outpatient
--------none--------
30 day limit/benefit period.
Mental/behavioral health visits count
towards your substance abuse limit.
Alcoholism treatment (Non-Network)
emergency detoxification - 3 day limit.
Residential treatment - 10 days.
Substance Abuse Inpatient (Non-
Network) limited to 1 day. Inpatient
and outpatient substance abuse
rehabilitation programs are limited to 2
episodes per lifetime (In-Network and
Non-Network).
Maternity care may include tests and
services described elsewhere in the
SBC (i.e. ultrasound).
ce 30% coinsurance 100 visits/benefit period. Limit does
not include I.V. therapy.
ce 30% coinsurance *See Therapy Services section
ce 30% coinsurance
ce 30% coinsurance 100 day limit/benefit period.
ce 30% coinsurance *See Durable Medical Equipment
Section
document at https://eoc.anthem.com/eocdps/fi.
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