Page 22 - Benefits Summary 2018-2019 b_Neat

General Services In-Network Out-of-Network
Unlimited
Lifetime maximum
Per individual
Unlimited
Out-of-network annual maximum
Per individual
Emergency room care You pay $200 per visit copay (waived if admitted),
 All services rendered apply to ER benefit then plan pays 100%
including Lab & X-ray
After the in-network plan deductible is met,
Ambulance You pay 0%
Plan pays 100%
After the plan deductible is met,
You pay $30 per visit copay,
Office surgery – PCP You pay 30%
then plan pays 100%
Plan pays 70%
After the plan deductible is met,
You pay $50 per visit copay,
Office surgery – Specialist You pay 30%
then plan pays 100%
Plan pays 70%
Covered same as plan’s Covered same as plan’s
Other office services – laboratory
Physician’s Office Services Physician’s Office Services
Covered same as plan’s Covered same as plan’s
Other office services – radiology
Physician’s Office Services Physician’s Office Services
After the plan deductible is met,
Plan pays 100%,
Outpatient lab You pay 30%
no deductible
Plan pays 70%
After the plan deductible is met,
Plan pays 100%,
Outpatient radiology You pay 30%
no deductible
Plan pays 70%
After the plan deductible is met,
Plan pays 100%,
Independent lab You pay 30%
no deductible
Plan pays 70%
Office advanced radiology imaging services
 Copay would apply once per day, per provider You pay $150 copay, then plan After the plan deductible is met,
for the services pays 100% You pay 30%
 Includes MRI, MRA, PET, CT-Scan and Plan pays 70%
Nuclear medicine
Outpatient advanced radiology imaging services You pay $150 copay, then plan After the plan deductible is met,
 Includes MRI, MRA, PET, CT-Scan and pays 100% You pay 30%
Nuclear medicine Plan pays 70%
Durable medical equipment After the plan deductible is met, After the plan deductible is met,
 Includes external prosthetic appliances You pay 0% You pay 30%
 Does accumulate towards the out-of-pocket Plan pays 100% Plan pays 70%
maximum
Breast Feeding Equipment and Supplies Plan pays 100%, After the plan deductible is met,
 Limited to the rental of one breast pump per no copay, You pay 30%
birth as ordered or prescribed by a physician. no deductible Plan pays 70%
Includes related supplies

Benefits In-Network Out-of-Network
Hospital Services

11/1/2018
ASO
Open Access Plus - OAP High 11-2018 - 7899546. Version# 12

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