Page 56 - Benefits Summary 2018-2019

Benefits In-Network Out-of-Network
Outpatient physical therapy After the plan deductible is met, After the plan deductible is met,
 20 visits per plan year You pay 0% You pay 30%
 Limits are not applicable to mental health Plan pays 100% Plan pays 70%
conditions
Outpatient speech therapy, hearing therapy and
occupational therapy After the plan deductible is met, After the plan deductible is met,
 20 visits per plan year You pay 0% You pay 30%
 Limits are not applicable to mental health Plan pays 100% Plan pays 70%
conditions for speech and occupational
therapies
After the plan deductible is met, After the plan deductible is met,
Chiropractic services You pay 0% You pay 30%
 20 visits per plan year
Plan pays 100% Plan pays 70%
Acupuncture Not Covered Not Covered
Additional Services
Medical Specialty Drugs Inpatient Facility
 This benefit applies to the cost of the Infusion After the plan deductible is met, After the plan deductible is met,
Therapy drugs administered in an Inpatient You pay 0% You pay 30%
Facility. This benefit does not cover the related Plan pays 100% Plan pays 70%
Facility or Professional charges.
Medical Specialty Drugs Outpatient Facility
 This benefit applies to the cost of the Infusion After the plan deductible is met, After the plan deductible is met,
Therapy drugs administered in an Outpatient You pay 0% You pay 30%
Facility. This benefit does not cover the related Plan pays 100% Plan pays 70%
Facility or Professional charges.
Medical Specialty Drugs Physician’s Office
 This benefit applies to the cost of targeted After the plan deductible is met, After the plan deductible is met,
Infusion Therapy drugs administered in the You pay 0% You pay 30%
Physician’s Office. This benefit does not cover Plan pays 100% Plan pays 70%
the related Office Visit or Professional charges.
Medical Specialty Drugs Home
 This benefit applies to the cost of targeted After the plan deductible is met, After the plan deductible is met,
Infusion Therapy drugs administered in the You pay 0% You pay 30%
patient’s home. This benefit does not cover the Plan pays 100% Plan pays 70%
related Professional charges.
PPACA Women’s Health
 Includes surgical services, such as tubal Plan pays 100%, Varies based on place of
ligation (excludes reversals) no copay,no deductible service
 Contraceptive devices are included.
Family planning
 Includes surgical services, such as vasectomy Varies based on place of Not Covered
(excludes reversals) service
 Includes infertility testing for diagnosis only
Infertility Not Covered Not Covered
Abortion Varies based on place of Varies based on place of
 Includes non-elective procedures service service
 Includes elective procedures in-network only
After the plan deductible is met,
Varies based on place of
TMJ You pay 30%
service
Plan pays 70%

11/1/2018
ASO
Health Savings Account Open Access Plus - HSA OAP 11-2018 - 7900133. Version# 12

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