Page 4 - Benefits Summary 2018-2019 b_Neat

General Services In-Network
Plan pays 100%,
Outpatient radiology
no deductible
Plan pays 100%,
Independent lab
no deductible
Office advanced radiology imaging services
 Copay would apply once per day, per provider
for the services You pay $300 copay, then plan pays 100%
 Includes MRI, MRA, PET, CT-Scan and
Nuclear medicine
Outpatient advanced radiology imaging services
 Includes MRI, MRA, PET, CT-Scan and You pay $300 copay, then plan pays 100%
Nuclear medicine
Durable medical equipment After the plan deductible is met,
 Includes external prosthetic appliances You pay 30%
 Does accumulate towards the out-of-pocket Plan pays 70%
maximum
Breast Feeding Equipment and Supplies Plan pays 100%,
 Limited to the rental of one breast pump per no copay,
birth as ordered or prescribed by a physician. no deductible
Includes related supplies

Benefits In-Network
Hospital Services
Inpatient hospital services You pay $350 per admission deductible,
 $350 in-network per admission deductible is Then
separate and in addition to the plan deductible. You pay 30%
Plan deductible only applies to the Professional Plan pays 70%
Services.
Inpatient Professional Services After the plan deductible is met,
 For services performed by Surgeons, You pay 30%
Radiologists, Pathologists, Anesthesiologists, Plan pays 70%
and Hospital Based Physician
After the plan deductible is met,
Outpatient hospital services You pay 30%
Plan pays 70%
Outpatient professional services After the plan deductible is met,
 For services performed by Surgeons, You pay 30%
Radiologists, Pathologists, Anesthesiologists Plan pays 70%
After the plan deductible is met,
Skilled nursing facility care You pay 30%
 60 days per plan year maximum
Plan pays 70%
After the plan deductible is met,
Hospice care You pay 30%
Plan pays 70%
Home health care
 60 visits per plan year maximum After the plan deductible is met,
You pay 30%
 The limit is not applicable to mental health and Plan pays 70%
substance use disorder conditions.
Mental Health and Substance Use Disorder
Inpatient mental health You pay $350 per admission deductible,
 Includes Residential Treatment then you pay 30%, Plan pays 70%

11/1/2018
ASO
Open Access Plus - OAPin Low 11-2018 - 7899882. Version# 12

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