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HSA Plan

Network

20% coinsurance after deductible

Non-Network

40% coinsurance after deductible

PPO 750 Plan

Network

Inpatient: $200 copayment plus 20% coinsurance after deductible

Other: 20% coinsurance after deductible

Non-Network

Inpatient: $200 copayment plus 40% coinsurance after deductible

Other: 40% coinsurance after deductible

PPO 1250 Plan

Network

Inpatient: $200 copayment plus 20% coinsurance after deductible

Other: 20% coinsurance after deductible

Non-Network

Inpatient: $200 copayment plus 40% coinsurance after deductible

Other: 40% coinsurance after deductible

Covered benefits include:

  • Semi-private room and board. For network charges, this rate is based on network repricing. For non-network charges, any charge over a semi-private room charge will be a covered expense only when clinical eligibility for coverage is met. If the hospital has no semi-private rooms, the plan will allow the private room rate subject to usual, customary, and reasonable charges (UCR) or the network negotiated rate, whichever is applicable.
  • Intensive care unit room and board.
  • Surgery, therapies and ancillary services including, but not limited to:
    • Blood, blood plasma and plasma expanders, when not available without charge;
    • Cornea transplant;
    • Breast reconstruction surgery or prostheses following mastectomy and lumpectomy is available to both females and males. A diagnosis of breast cancer is not required for breast reconstruction services to be covered, and the timing of reconstructive services is not a factor in coverage;
    • Cosmetic/reconstructive surgery to repair a functional disorder caused by disease or injury;
    • Cosmetic/reconstructive surgery to repair a congenital defect or abnormality for a member younger than nineteen; and
    • Sterilization for the purpose of birth control.

Certain types of services such as radiology, anesthesiology and pathology are sometimes performed by non-network providers in a network facility. Expenses for these services are paid as network benefits and are not subject to UCR.

Except for observation, preauthorization by medical plan is required.

See also: Mental Health Services (Includes Inpatient and Outpatient)


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