Page 13 - 2015 Advia CU Benefits & Notices
P. 13
Advia CU - MI 2015
Advia CU BCN HMO HRA 1000 Plan In Network
Benefit Summary
Deductible and Coinsurance Maximums $1,000 Single / $2,000 Family
Deductible 50% for few services
Coinsurance (Percentage copays) None
Annual Coinsurance Out-of-Pocket Max
Total Annual Out-of-Pocket Maximum* $6,350 Single / $12,700 Family
* Includes all deductible, co-insurance and fixed dollar copays
Prescription Drugs
SEE NEXT PAGE
Preventive Services 100% (one per calendar year)
Health Maintenance Exam 100% (one per calendar year)
Annual Gynecological Exam & PAP 100% (one per calendar year)
Prostate Specific Antigen (PSA) Screening 100% (one per calendar year)
Mammography Screening 100% (one per calendar year)
Expanded Women’s Preventive Care 100% (one per calendar year)
Well-Baby and Child Care 100% (one per calendar year)
Immunizations – pediatric & adult 100% (one per calendar year)
Colonoscopy – screening or diagnostic
Physician Office Visits $15 copay / $30 copay
Office visits, Specialist visits
Emergency Medical Care $100 copay per visits (waived only if admitted)
Hospital Emergency Room $45 copay
Facility Based Urgent Care Center $25 copay
Ambulance Services (air/ground)
Diagnostic Services Office Visit copay may apply per member, per visit
Lab & Pathology Tests Office Visit copay may apply per member, per visit AFTER DEDUCTIBLE
Diagnostic Tests & X-Rays
High Tech Radiology Imaging $150 copay or 50% of approved amount
Radiation Therapy Office Visit copay may apply per member, per visit AFTER DEDUCTIBLE
Maternity Services
Pre and Post-natal Care $15 copay
Delivery & Nursery Care 100% after deductible
Hospital Care
Semi-Private Room, Inpatient physician care, Hospital 100% after deductible
services and supplies 100% after deductible
Inpatient Medical Care & Chemotherapy
Alternatives to Hospital Care 100% after deductible
Skilled Nursing Care 100% after deductible
Hospice Care
Surgical Services 100% after deductible
Surgery – includes related surgical services and medically 50% after deductible
necessary in or out-patient facility charges
Voluntary Sterilization & selected procedures 100% after deductible
Human Organ Transplants 100% after deductible
Specified Organ Transplants
Bone Marrow & Other Transplants 100% after deductible
Mental Health & Substance Abuse Treatment $15 copay
In Patient Mental & Substance Abuse Treatment
$30 copay
Out Patient Mental & Substance Abuse Treatment 100% Covered
Other Services
Chiropractic Care – REFERRAL REQUIRED $30 copay
DME, P&O appliances 50% after deductible
O/P Occ/SP/Physical Therapy (60) 50% after deductible
Allergy Testing & Therapy 50% after deductible
Weight Reductions Procedures
Infertility Counseling /Treatment Salus Group© Copyright 2014
Page | 13
Advia CU BCN HMO HRA 1000 Plan In Network
Benefit Summary
Deductible and Coinsurance Maximums $1,000 Single / $2,000 Family
Deductible 50% for few services
Coinsurance (Percentage copays) None
Annual Coinsurance Out-of-Pocket Max
Total Annual Out-of-Pocket Maximum* $6,350 Single / $12,700 Family
* Includes all deductible, co-insurance and fixed dollar copays
Prescription Drugs
SEE NEXT PAGE
Preventive Services 100% (one per calendar year)
Health Maintenance Exam 100% (one per calendar year)
Annual Gynecological Exam & PAP 100% (one per calendar year)
Prostate Specific Antigen (PSA) Screening 100% (one per calendar year)
Mammography Screening 100% (one per calendar year)
Expanded Women’s Preventive Care 100% (one per calendar year)
Well-Baby and Child Care 100% (one per calendar year)
Immunizations – pediatric & adult 100% (one per calendar year)
Colonoscopy – screening or diagnostic
Physician Office Visits $15 copay / $30 copay
Office visits, Specialist visits
Emergency Medical Care $100 copay per visits (waived only if admitted)
Hospital Emergency Room $45 copay
Facility Based Urgent Care Center $25 copay
Ambulance Services (air/ground)
Diagnostic Services Office Visit copay may apply per member, per visit
Lab & Pathology Tests Office Visit copay may apply per member, per visit AFTER DEDUCTIBLE
Diagnostic Tests & X-Rays
High Tech Radiology Imaging $150 copay or 50% of approved amount
Radiation Therapy Office Visit copay may apply per member, per visit AFTER DEDUCTIBLE
Maternity Services
Pre and Post-natal Care $15 copay
Delivery & Nursery Care 100% after deductible
Hospital Care
Semi-Private Room, Inpatient physician care, Hospital 100% after deductible
services and supplies 100% after deductible
Inpatient Medical Care & Chemotherapy
Alternatives to Hospital Care 100% after deductible
Skilled Nursing Care 100% after deductible
Hospice Care
Surgical Services 100% after deductible
Surgery – includes related surgical services and medically 50% after deductible
necessary in or out-patient facility charges
Voluntary Sterilization & selected procedures 100% after deductible
Human Organ Transplants 100% after deductible
Specified Organ Transplants
Bone Marrow & Other Transplants 100% after deductible
Mental Health & Substance Abuse Treatment $15 copay
In Patient Mental & Substance Abuse Treatment
$30 copay
Out Patient Mental & Substance Abuse Treatment 100% Covered
Other Services
Chiropractic Care – REFERRAL REQUIRED $30 copay
DME, P&O appliances 50% after deductible
O/P Occ/SP/Physical Therapy (60) 50% after deductible
Allergy Testing & Therapy 50% after deductible
Weight Reductions Procedures
Infertility Counseling /Treatment Salus Group© Copyright 2014
Page | 13
