Page 42 - Benefits Book Tanner Manor 2020
P. 42
Limitations, Exceptions & Other Important Information
QHWZRUN SURYLGHU benefit, you must obtain SURYLGHU as designated by us. Call 1-800-325-1404 for further information. 6SHFLDOW\ GUXJV obtained from a non-designated specialty SURYLGHU will not be covered. Authorization is VSHFLDOW\ GUXJV that are not authorized by the Medical Review Manager. 3UHDXWKRUL]DWLRQ is required. If not received, a penalty will be 3UHDXWKRUL]DWLRQ is required. If not received, a penalty will be Non-emergency use will result in a reduction
To receive the VSHFLDOW\ GUXJV from a specialty pharmacy pharmacy required. Benefits will not be paid for any applied. applied. the covered. sickness or injury. None applied. applied. services covered under your FRLQVXUDQFH. and applied.
FRSD\/visit for
What You Will Pay FRSD\/visit for Primary Care Provider; $60
FRLQVXUDQFH FRLQVXUDQFH FRLQVXUDQFH FRLQVXUDQFH FRLQVXUDQFH FRSD\/visit, then covered at 100% FRLQVXUDQFH FRLQVXUDQFH FRLQVXUDQFH
30% 30% 30% 30% 30% $75 30% 30% $40 6SHFLDOLVW 30%
Services You May Need 6SHFLDOW\ GUXJV Facility fee (e.g., ambulatory surgery center) Physician/surgeon fees (PHUJHQF\ URRP FDUH (PHUJHQF\ PHGLFDO WUDQVSRUWDWLRQ 8UJHQW FDUH Facility fee (e.g., hospital room) Physician/surgeon fees Outpatient services Inpatient services
Common Medical Event If you have outpatient surgery If you need immediate medical attention If you have a hospital stay If you need mental health, behavioral health, or substance abuse services
