applies 80% of the Fund's UCR; deductible applies Not Covered 100% of the Fund's Negotiated rate; deductible
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1 Adoption $10, Calendar year maximum; Acupuncture 80% of the Fund's UCR; deductible 16 visits per Calendar Year; 1 visit per day; Allergy Injections 80% of the Fund's UCR; deductible Allergy Treatment 80% of the Fund's UCR; deductible Ambulance True Emergent 100%; deductible waived Ambulance Non Emergent 80% of the Fund's UCR; deductible Ambulatory Surgery Not Covered Non Participating Free Standing Surgical Centers / Ambulatory Surgical facility charges are not a covered expense Anesthesia 80% of the Fund's UCR; deductible Anesthesia Maternity 100% of the negotiated rated; deductible Annual Physical 80% of the Fund's UCR; deductible Assistant Surgeon 80% of the Fund's UCR; deductible Birthing Center 100%of the negotiated rate; deductible Not Covered Breast Sonogram 80% of Fund's UCR; deductible Cardiac Rehabilitation 80% of the Fund's UCR; deductible 36 visits per Calendar Year Chemotherapy Chiro 100% of the Fund's UCR; deductible 1 visit per day; 24 visits per Calendar Year; Chiro X-rays 80% of the Fund's UCR; deductible 4 x-rays per Calendar Year Diabetic Supplies 80% of the Fund's UCR; deductible Diabetic Education with Dietician 80% of the Fund's UCR; deductible Diagnostic Testing Office 80% of the Fund's UCR; deductible Diagnostic Independent lab / Professional charge 80% of the Fund's UCR; deductible Diagnostic Testing OP / Hospital Charge 80% of the Fund's UCR; deductible
2 Diagnostic Testing OP in Free Standing Facility 100% of negotiated rate; deductible 80% of the Funds UCR; deductible Breast Sonogram 80% of the Fund's UCR; deductible Pulmonary Function Test 80% of the Fund's UCR; deductible Tilt Table Testing 80% of the Fund's UCR; deductible Electrophysiological Study 80% of the Fund's UCR; deductible Video EEG 80% of the Fund's UCR; deductible Mammogram 80% of the Fund's UCR; deductible Dialysis Office Dialysis OP Facility Dialysis OP Physician 80% of the Fund's Negotiated rate; deductible Dietician / Nutritionist 80% of the Fund's UCR; deductible 6 visits per Calendar Year DELM Digital Dermoscopy Exam 80% of the Fund's UCR; deductible 2 visits per Calendar Year DME / Medical Equipment 80% of the Fund's UCR; deductible Prior approval by the Fund is ER Non Emergent Facility Not Covered 80% of the Fund's UCR; deductible ER Emergent Facility waived waived ER Non Emergent Physician 80% of the Fund's UCR; deductible ER Emergent Physician Gastric Bypass Physician 80% of the Fund's UCR; deductible ; $ Calendar year maximum combined physician charges; Prior approval ; Gastric Assistant Surgeon 80% of the Fund's UCR; deductible $ Calendar year maximum combined physician charges; Prior approval ; Genetic Testing -independent lab 80% of the Fund's UCR; deductible Genetic Counciling not covered. Genetic Testing-OP Hospital 80% of the Fund's UCR; deductible Genetic Counciling not covered. Halfway House Not Covered Not Covered Hearing Aid Right 100% of the Fund's UCR; deductible $ per Calendar year maximum Hearing Aid Left 100% of the Fund's UCR; deductible $ per Calendar year maximum
3 Hospice Care home Inpatient Rehabilitation (Physical, Occupational, Speech) Medical Benefits for eligible Active Working Home Health Care ; 100% of the Fund's UCR; deductible ; 200 visits per Calendar Year; prior approval is Hospice Care IP 100% of the Fund's UCR; deductible 210 days per Calendar Year 100% of the Fund's UCR; deductible 210 days per Calendar Year Immunizations IUD supplies Infertility Anesthesia Infertility Facility Infertility Pathology / Lab waived; up to 30 days per calendar year waived; up to 30 days per calendar year 80% of the Fund's UCR; deductible 80% of the Fund's UCR; deductible 80% of the Fund's UCR; deductible waived 100% of the Fund's UCR; deductible waived 80% of the Fund's UCR; deductible Infertility /Rx 80% of the Fund's UCR; deductible Infertility Physician 80% of the Fund's UCR; deductible Inpatient hospital Illness / Room & Board 100% of the negotiated rated 100% of the Fund's negotiated rate up to 120 days Lap Band 80% of the Fund's UCR; deductible $ Calendar year maximum combined physician charges; prior approval by the fund is Lasik Surgery Physician Left eye 80% of the Fund's UCR; deductible $1, global allowance; prior approval Lasik Surgery Physician Right eye 80% of the Fund's UCR; deductible $1, global allowance; prior approval Lithotripsy Physician 80% of the Fund's UCR; deductible Lithotripsy Facility 100% of the negotiated rate 100% of the Fund's Negotiated rate Maternity C Section 100% of the Fund's UCR; deductible ; $4,000 per delivery Maternity Midwife 100% of the Fund's UCR; deductible ; $3,200 per delivery Maternity Regular Delivery 100% of the Fund's UCR; deductible ; $3,600 per delivery Medical Equipment / Rentals and Purchases 100% of the Fund's UCR; deductible Prior approval by the Fund is
4 Medication Coverage Outside Of The RX Plan J codes for Hep C, Cancer, MS, HIV/AIDS, Epilepsy, Crohn's Disease and Diabetes; Arthritis; prior approval through the Fund is. Abuse Inpatient Up to 120 days per Calendar year; prior approval through the fund is Abuse Outpatient MD 100% of Fund's UCR; deductible $ per visit; prior approval through the fund is Abuse Outpatient Social Worker 100% of Fund's UCR; deductible $85.00 per visit; prior approval through the fund is Abuse Outpatient Group $55.00 per visit; prior approval through the fund Therapy 100% of Fund's UCR; deductible is Abuse Outpatient Family Therapy 100% of Fund's UCR; deductible $55.00 per visit; prior approval through the fund is Newborn Hearing IP Physician charges Nerve Block Injections 80% of the Fund's UCR; deductible up to 4 per Calendar Year; Neuropsychological Testing 80% of the Fund's UCR; deductible 12 units per test per Calendar Year; prior approval Occupational Therapy 100% of the Fund's UCR; deductible Physical Therapy 100% of the Fund's UCR; deductible Podiatry 80% of the Fund's UCR; deductible Speech Therapy 100% of the Fund's UCR; deductible Visual Therapy 100% of the Fund's UCR; deductible Orthotics 80% of the Fund's UCR; deductible Orthotripsy 80% of the Fund's UCR; deductible Office visit Specialits 80% of the Fund's UCR; deductible Office visit MD 80% of the Fund's UCR; deductible Office Consult / Initial Specialist 80% of the Fund's UCR; deductible Prior approval through the fund is for surgery. PT and strapping not covered. Prior approval is ; 1 pair of orthotics per Calendar year $4, per Calendar year; Prior approval
5 Office Consult / Initial MD 80% of the Fund's UCR; deductible Office Surgery Physician charges 80% of the Fund's UCR; deductible Partial Hospitalization Inpatient or Out patient Not Covered Not Covered Pathology Physician IP Pathology Outpatient 80% of the Fund's UCR; deductible PEMG waived Pharmocogenetic 80% of the Fund's UCR; deductible Private Duty Nursing 80% of the Fund's UCR; deductible $10, per Calendar year; Prior approval Pre-Surgical Testing Must be performed with seven days of the surgical procedure. Prosthetics 80% of the Fund's UCR; deductible Prior approval Pulmonary Rehab 80% of the Fund's UCR; deductible 42 visits per Calendar year Reconstructive Surgery 80% of the Fund's UCR; deductible Prior approval through the fund is. Routine / Physical 80% of the Fund's UCR; deductible Sclerotherapy 80% of the Fund's UCR; deductible 2 visits per Calendar year maximum; Prior approval through the fund is. Skilled Nursing Facility 100% of the negotiated rate 100% of the Fund's negotiated rate 60 days per Calendar year; Sleep Study ; up to a maximum of $3,000 80% of the Fund's negotiated rate; deductible ; up to a maximum of $3,000 $3,000 per Calendar year; prior approval is. Surgical Center 100% of the negotiated rate Not Covered Swift MD Synagis injections 80% of the Fund's UCR; deductible Ultrasound Pregnancy first three 80% of the Fund's UCR; deductible Ultrasound Pregnancy after the three limit 80% of the Fund's UCR; deductible Prior approval Urgent Care Centers Not Covered Not Covered
6 Wig
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