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HSA Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

PPO 750 Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

PPO 1250 Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

Coverage for an electrocardiographically-monitored program of outpatient cardiac rehabilitation (Phase II) when it is individually prescribed by a provider and a formal exercise stress test is completed after the event and before beginning the program. Up to 36 visits within a 12-week period per incident without preauthorization.

Cardiac rehabilitation is covered if referred by a provider, for members who have had 1 of the following:

  • Acute myocardial infarction (MI) (heart attack in the last 12 months);
  • Coronary artery bypass grafting (CABG);
  • Stable angina pectoris;
  • Percutaneous coronary vessel remodeling;
  • Valve replacement or repair;
  • Heart transplant;
  • Coronary artery disease (CAD) associated with chronic stable angina that has failed to respond adequately to prescription drug therapy and is interfering with the ability to perform age-related activities of daily living and/or impairing functional abilities;
  • Heart failure that has failed to respond adequately to prescription drug therapy and is interfering with the ability to perform age-related activities of daily living and/or impairing functional abilities.

Preauthorization by medical plan is required for any visits after the first 36 within a 12-week period per incident if services continue to be medically necessary.


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