Page 15 - 2015 Advia CU Benefits & Notices
P. 15
Advia CU - MI 2015
Advia CU BCN HMO HSA 1300 Plan In Network
Benefit Summary
Deductible and Coinsurance Maximums $1,300 Single / $2,600 Family
Deductible 20% or 50% for services noted
Coinsurance (Percentage copays)
Annual Coinsurance Out-of-Pocket Max None
Total Annual Out-of-Pocket Maximum* $2,300 Single / $4,600 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 80% after deductible
Office visits, Specialist visits
Emergency Medical Care 80% after deductible
Hospital Emergency Room 80% after deductible
Facility Based Urgent Care Center 80% after deductible
Ambulance Services (air/ground)
Diagnostic Services 80% after deductible
Lab & Pathology Tests 80% after deductible
Diagnostic Tests & X-Rays 80% after deductible
High Tech Radiology Imaging 80% after deductible
Radiation Therapy
Maternity Services 80% after deductible
Pre and Post-natal Care 80% after deductible
Delivery & Nursery Care
Hospital Care 80% after deductible
Semi-Private Room, Inpatient physician care, Hospital
services and supplies 80% after deductible
Inpatient Medical Care & Chemotherapy
Alternatives to Hospital Care 80% after deductible
Skilled Nursing Care up to 45 days 80% after deductible
Hospice Care
Surgical Services 80% after deductible
Surgery – includes related surgical services and medically 50% after deductible
necessary in or out-patient facility charges
Voluntary Sterilization (MALE) or Elective Abortion 100% after deductible
Human Organ Transplants 100% after deductible
Specified Organ Transplants
Bone Marrow & Other Transplants 80% after deductible
Mental Health & Substance Abuse Treatment 80% after deductible
In Patient Mental & Substance Abuse Treatment
Out Patient Mental & Substance Abuse Treatment 80% after deductible
Other Services 80% after deductible
Chiropractic Care – REFERRAL REQUIRED 80% after deductible
Diabetic Supplies 50% after deductible
O/P Occ/SP/Physical Therapy (60) 50% after deductible
Allergy Testing & Therapy 50% after deductible
Weight Reductions Procedures 50% after deductible
Infertility Counseling /Treatment Salus Group© Copyright 2014
DME, P&O appliances
Page | 15
Advia CU BCN HMO HSA 1300 Plan In Network
Benefit Summary
Deductible and Coinsurance Maximums $1,300 Single / $2,600 Family
Deductible 20% or 50% for services noted
Coinsurance (Percentage copays)
Annual Coinsurance Out-of-Pocket Max None
Total Annual Out-of-Pocket Maximum* $2,300 Single / $4,600 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 80% after deductible
Office visits, Specialist visits
Emergency Medical Care 80% after deductible
Hospital Emergency Room 80% after deductible
Facility Based Urgent Care Center 80% after deductible
Ambulance Services (air/ground)
Diagnostic Services 80% after deductible
Lab & Pathology Tests 80% after deductible
Diagnostic Tests & X-Rays 80% after deductible
High Tech Radiology Imaging 80% after deductible
Radiation Therapy
Maternity Services 80% after deductible
Pre and Post-natal Care 80% after deductible
Delivery & Nursery Care
Hospital Care 80% after deductible
Semi-Private Room, Inpatient physician care, Hospital
services and supplies 80% after deductible
Inpatient Medical Care & Chemotherapy
Alternatives to Hospital Care 80% after deductible
Skilled Nursing Care up to 45 days 80% after deductible
Hospice Care
Surgical Services 80% after deductible
Surgery – includes related surgical services and medically 50% after deductible
necessary in or out-patient facility charges
Voluntary Sterilization (MALE) or Elective Abortion 100% after deductible
Human Organ Transplants 100% after deductible
Specified Organ Transplants
Bone Marrow & Other Transplants 80% after deductible
Mental Health & Substance Abuse Treatment 80% after deductible
In Patient Mental & Substance Abuse Treatment
Out Patient Mental & Substance Abuse Treatment 80% after deductible
Other Services 80% after deductible
Chiropractic Care – REFERRAL REQUIRED 80% after deductible
Diabetic Supplies 50% after deductible
O/P Occ/SP/Physical Therapy (60) 50% after deductible
Allergy Testing & Therapy 50% after deductible
Weight Reductions Procedures 50% after deductible
Infertility Counseling /Treatment Salus Group© Copyright 2014
DME, P&O appliances
Page | 15
