Page 93 - Cover Letter and Evaluation for Patricia Hendrickson

Inpatient Hospital and Other Health Care Facilities Outpatient Services
Benefit
Benefit Amount Benefit Amount
Hospice Plan pays 80% ^ Plan pays 80% ^
Bereavement Counseling Plan pays 80% ^ Plan pays 80% ^
Note: Services provided as part of Hospice Care Program
Note: Services where plan deductible applies are noted with a caret (^)
Global Maternity Fee Office Visits in Addition to Delivery - Facility
Initial Visit to Confirm (All Subsequent Prenatal Visits, Global Maternity Fee (Inpatient Hospital, Birthing
Benefit Pregnancy Postnatal Visits and Physician's (Performed by OB/GYN or Center)
Delivery Charges) Specialist)
Benefit Amount Benefit Amount Benefit Amount Benefit Amount
Covered same as plan's Inpatient
Maternity Plan pays 80% ^ Plan pays 80% ^ Plan pays 80% ^
Hospital benefit
Note: Services where plan deductible applies are noted with a caret (^)
Inpatient Professional Outpatient Professional
Physician's Office Inpatient Facility Outpatient Facility
Benefit Services Services
Benefit Amount Benefit Amount Benefit Amount Benefit Amount Benefit Amount
Abortion
(Elective and
non-elective Plan pays 80% ^ Plan pays 80% ^ Plan pays 80% ^ Plan pays 80% ^ Plan pays 80% ^
procedures)
Family
Planning Plan pays 80% ^ Plan pays 80% ^ Plan pays 80% ^ Plan pays 80% ^ Plan pays 80% ^
Includes surgical services, such as tubal ligation or vasectomy (excludes reversals)
Infertility Plan pays 80% ^ Plan pays 80% ^ Plan pays 80% ^ Plan pays 80% ^ Plan pays 80% ^

Infertility covered services: lab and radiology test, counseling, surgical treatment, includes artificial insemination, in-vitro fertilization, GIFT, ZIFT, etc.
$10,000 lifetime maximum
TMJ, Surgical
and Non- Plan pays 80% ^ Plan pays 80% ^ Plan pays 80% ^ Plan pays 80% ^ Plan pays 80% ^
Surgical
Services provided on a case-by-case basis. Always excludes appliances & orthodontic treatment. Subject to medical necessity.
Unlimited maximum per lifetime
Orthognathic
Surgery Plan pays 80% ^ Plan pays 80% ^ Plan pays 80% ^ Plan pays 80% ^ Plan pays 80% ^
Bariatric
Surgery Plan pays 80% ^ Plan pays 80% ^ Plan pays 80% ^ Plan pays 80% ^ Plan pays 80% ^
Surgeon Charges Lifetime Maximum: Unlimited

1/1/2017
ASO
Comprehensive Indemnity - Comprehensive - Indemnity Medicare Plan - Retirees Over 65 - 5295897. Version# 6

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