Page 44 - University of the South-2022-Benefit Guide REVISED 3.30.22 FSA WAIT PERIOD

What You Will Pay
Common Out-of-Network Limitations, Exceptions, & Other Important
Medical Event Services You May Need In-Network Provider Provider Information
(You will pay the least) (You will pay the most)
Facility fee (e.g., hospital Prior Authorization required. Your cost share
If you have a room) 20% coinsurance 40% coinsurance may increase to 50% if not obtained.
hospital stay Prior Authorization required. Your cost share
Physician/surgeon fees 20% coinsurance 40% coinsurance
may increase to 50% if not obtained.
$30 copay/visit
If you need mental deductible does not Prior Authorization required for electro-
health, behavioral Outpatient services apply for office visits 40% coinsurance convulsive therapy (ECT). Your cost share
health, or and 20% coinsurance may increase to 50% if not obtained.
substance abuse other outpatient services
services Prior Authorization required. Your cost share
Inpatient services 20% coinsurance 40% coinsurance
may increase to 50% if not obtained.
$30 copay/visit
Office visits deductible does not 40% coinsurance PhysicianNow - Powered by MDLIVE: $15
copay
apply.
This service may be covered under the
Childbirth/delivery 20% coinsurance 40% coinsurance Specialty Care Program. Cost Share may
If you are pregnant professional services vary; use a Blue Distinction Center for best
benefit.
This service may be covered under the
Childbirth/delivery facility Specialty Care Program. Cost Share may
services 20% coinsurance 40% coinsurance vary; use a Blue Distinction Center for best
benefit.
Home health care No Charge 40% coinsurance Unlimited.
Therapy limited to 30 visits per type per year.
Rehabilitation services 20% coinsurance 40% coinsurance Cardiac/Pulmonary rehab limited to 36 visits
per type per year.
Therapy limited to 30 visits per type per year.
Habilitation services 20% coinsurance 40% coinsurance Cardiac/Pulmonary rehab limited to 36 visits
If you need help per type per year.
recovering or have
other special Skilled nursing care 20% coinsurance 40% coinsurance Skilled nursing and rehabilitation facility
health needs limited to 100 days combined per year.
Durable medical 20% coinsurance 40% coinsurance Prior Authorization may be required for
certain durable medical equipment. Your cost
equipment
share may increase to 50% if not obtained.
Prior Authorization required for inpatient
Hospice services No Charge 40% coinsurance hospice. Your cost share may increase to
50% if not obtained.
Children’s eye exam Not Covered Not Covered None
If your child needs Children’s glasses Not Covered Not Covered None
dental or eye care Children’s dental Not Covered Not Covered None
check-up
Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Bariatric surgery • Infertility treatment • Routine eye care (Adult)
• Cosmetic surgery • Long-term care • Routine eye care (Children)
• Dental care (Adult) • Non-emergency care when traveling outside the • Routine foot care for non-diabetics
• Dental care (Children) U.S. • Weight loss programs
• Hearing aids for adults • Private-duty nursing
Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Acupuncture • Hearing aids for children under 18 • Chiropractic care

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