Common use of Maximum Out of Pocket Clause in Contracts

Maximum Out of Pocket. Expense The maximum out-of-pocket expense accumulates separately for network and non-network services. The deductible and copayments (including, but not limited to, office visits copayments and prescription drug copayments) apply to the maximum out-of- pocket expense. Individual Plan Per contract year $6,350 $9,600 Family Plan Per contract year $12,700 The contract year family maximum out-of- pocket expense is met by adding the amount of covered health care expenses applied to the maximum out-of-pocket expense for all family members; however no one family member can contribute more than $6,350 the individual maximum out-of-pocket expense amount towards the contract year family maximum out-of- pocket expense. $19,200 The contract year family maximum out-of- pocket expense is met by adding the amount of covered health care expenses applied to the maximum out-of-pocket expense for all family members; however no one family member can contribute more than $9,600 the individual maximum out-of-pocket expense amount towards the contract year family maximum out-of- pocket expense. Medical Benefits Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Ambulance Ground $50 NO The level of coverage is the same as Tier 1 network provider The level of coverage is the same as Tier 1 network provider Air/Water Up to the maximum benefit of $3,000 per occurrence $50 NO The level of coverage is the same as Tier 1 network provider The level of coverage is the same as Tier 1 network provider Behavioral Health - Mental Health Inpatient * Unlimited days at a general hospital or a specialty hospital. 30% YES 30% YES 70% YES Outpatient, Intermediate Care Services* See Section 3.3 for details. 0% NO 0% NO 70% YES In the office/in your home rendered by PCP ^ Includes individual and group sessions. $40 NO $40 for a member up to nineteen (19) years old NO 70% YES $60 for a member nineteen (19) and older In the office/in your home rendered by Specialist Includes individual and group sessions. $65 NO $65 NO 70% YES Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Behavioral Health – Substance Abuse Treatment Inpatient, Substance Abuse Treatment Facility * Detoxification – unlimited days per contract year. Residential Rehabilitation – unlimited days per contract year. 30% YES 30% YES 70% YES Outpatient In a Substance Abuse Treatment facility (out- patient), Intermediate Care Services * See Section 3.3 for details. 0% NO 0% NO 70% YES In the office/in your home rendered by PCP ^ $40 NO $40 for a member up to nineteen (19) years old NO 70% YES In the office/in your home rendered by Specialist $65 NO $65 NO 70% YES Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Behavioral Health – Substance Abuse Treatment Methadone Maintenance Treatment $65 NO $65 NO 70% YES Cardiac Rehabilitation Outpatient Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. See Section 3 for details. 30% YES 30% YES 70% YES Chiropractic Medicine In a Provider’s office^ 20 visits per contract year. $40 NO $60 NO 70% YES Dental Care Hospital Emergency Room When services are due to accidental injury to sound natural teeth. $350 NO The level of coverage is the same as Tier 1 network provider The level of coverage is the same as Tier 1 network provider Services connected to dental care performed in Outpatient Facility * See Section 3.7 for benefit limitations. 30% YES 30% YES 70% YES In an office (doctor or dentist) ^ When services are due to accidental injury to sound natural teeth. $65 NO $85 NO 70% YES Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Dental Care Rendered to enrolled children under the age of 19 Oral Evaluations Two examinations per benefit year. Exams include: The initial examination or periodic examination or emergency oral evaluation when performed by a general dentist including diagnosis and charting per benefit year. 0% NO 0% NO 0% NO X-rays Single x-rays limited to four (4) per six (6) month period. 0% NO 0% NO 0% NO Bitewing limited to one (1) set per benefit year. 0% NO 0% NO 0% NO Limited to one full mouth series (FMX) or panorex per 60-month period. 0% NO 0% NO 0% NO X-rays other than those listed above 50% NO 50% NO 50% NO Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Dental Care Rendered to enrolled children under the age of 19 Cleanings (Prophy- laxis) Two (2) cleanings per benefit year. 0% NO 0% NO 0% NO Fluoride Treatments Up to two (2) fluoride treatments for members under nineteen (19) years old per benefit year. 0% NO 0% NO 0% NO Sealants For permanent molars only. Limited to one per tooth in a 24- month period for members under nineteen (19) years old. 0% NO 0% NO 0% NO Space Maintainers 0% NO 0% NO 0% NO Palliative Treatment Minor treatment to relieve sudden, intense pain. 50% NO 50% NO 50% NO Fillings See Section for details. 50% NO 50% NO 50% NO Simple Extractions Removal of erupted tooth (non-surgical). 50% NO 50% NO 50% NO Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Dental Care Rendered to enrolled children under the age of 19 Denture Repairs and Relines/ Rebasing Full or partial dentures. Relines/Rebasing limited to once in a 60-month period. 50% NO 50% NO 50% NO Crowns & Onlays Predetermination is recommended. Replacement limited to once in a 60-month period. 50% NO 50% NO 50% NO Therapeutic Pulpotomies Limited to members under fourteen (14) years old. 50% NO 50% NO 50% NO Root Canal Therapy – Anterior (front) Teeth 50% NO 50% NO 50% NO Root Canal Therapy - Posterior (back) Teeth 50% NO 50% NO 50% NO Non- Surgical Periodontal Services 50% NO 50% NO 50% NO Surgical Periodontal Services Predetermination is recommended. 50% NO 50% NO 50% NO Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Dental Care Rendered to enrolled children under the age of 19 Periodontal Mainte- ▇▇▇▇▇ Limited to two (2) services in a benefit year. 50% NO 50% NO 50% NO Fixed Bridges and Dentures Coverage for replacements limited to one (per tooth/unit) in a 60-month period Crowns over implants are considered a prosthodontic service. Predetermination is recommended. 50% NO 50% NO 50% NO Single Tooth Implant Coverage if placed as an alternative treatment to a conventional 3- unit bridge Replacing only one missing tooth. Coverage for replacements limited to one (1) in a 60-month period. 50% NO 50% NO 50% NO Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Dental Care Rendered to enrolled children under the age of 19 Oral Surgery Services 50% NO 50% NO 50% NO General Anesthesia or IV Sedation Covered as a separate benefit when performed in conjunction with a covered oral surgery procedure(s). 50% NO 50% NO 50% NO Biopsies Limited to the biopsy and examination of oral tissue, soft or hard. 50% NO 50% NO 50% NO Occlusal (Night) guards Limited to one (1) every five (5) years. 50% NO 50% NO 50% NO Orthodontic Services (Braces) Predetermination is recommended. Only medically necessary braces are covered. 50% NO 50% NO 50% NO Diabetic Services Diabetic equipment/ supplies provided by a licensed medical supply provider (other than a pharmacy) 30% YES 30% YES 70% YES Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Diabetic Services Diabetic equipment/ supplies purchased at a retail pharmacy. See the Summary of Pharmacy Benefits for benefit limits and level of coverage. Office visits Podiatrist Services First routine visit of a contract year. See Section 3.8 for details. $0 NO $0 NO 70% YES Vision Care Service First routine eye exam of a contract year that includes a retinal eye exam. $0 NO $0 NO 70% YES Dialysis Services Inpatient/ Outpatient/ in your home 30% YES 30% YES 70% YES Durable Medical Equipment, Medical Supplies, Enteral Formu- la and Food, and Prosthetic Devices Outpatient Durable Medical Equipment* Preauthorization recommended for certain services. See Section 3.9 for details. Must be provided by a licensed medical supply provider. 30% YES 30% YES 70% YES Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Durable Medical Equipment, Medical Supplies, Enteral Formula and Food, and Prosthetic Devices Outpatient Medical Supplies* Must be provided by a licensed medical supply provider. 30% YES 30% YES 70% YES Outpatient Prosthesis* Must be provided by a licensed medical supply provider. 30% YES 30% YES 70% YES Enteral formula delivered through a feeding tube Must be sole source of nutrition. 30% YES 30% YES 70% YES Enteral formula or food taken orally* See Section 3.9 for details. 30% YES The level of coverage is the same as Tier 1 network provider The level of coverage is the same as Tier 1 network provider Hair Prosthesis (Wigs) Benefit is limited to the maximum benefit of $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 30% YES The level of coverage is the same as Tier 1 network provider. The level of coverage is the same as Tier 1 network provider. Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Early Intervention Services (EIS) Early Intervention Services (EIS) For children from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% NO The level of coverage is the same as Tier 1 network provider. The level of coverage is the same as Tier 1 network provider. Education Asthma Management 0% NO 0% NO 70% YES Experimental/ Investiga-tional Services Coverage varies based on type of service. See Section 3.12. Hearing Hearing Exam^ $65 NO $85 NO 70% YES Diagnostic Testing 30% YES 30% YES 70% YES Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear for a member 19 and older. 30% YES The level of coverage is the same as Tier 1 network provider. The level of coverage is the same as Tier 1 network provider. Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Coverage varies based on type of hemophilia service. 30% YES 30% YES 70% YES Home Health Care In your home Intermittent skilled services when billed by a home health care agency. 30% YES 30% YES 70% YES Hospice Care Inpatient/ In your home When provided by an approved hospice care program. 30% YES 30% YES 70% YES Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency $350 NO The level of coverage is the same as Tier 1. The level of coverage is the same as Tier 1. Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Human Leukocyte Antigen Testing ^ Outpatient Hospital facility and designated free standing facilities See Section 3.18 for limitations. $75 NO $75 NO 70% YES Non- Hospital facility including in a Doctor’s office, urgent care center, and designated freestanding outpatient facilities $25 NO $75 NO 70% YES Infertility Outpatient/ in a doctor’s office Three (3) infertility treatment cycles will be covered per benefit year with a total of eight (8) infertility treatment cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on 20% YES 20% YES 20% YES Service Service Type, Provider

Maximum Out of Pocket. Expense The maximum out-of-pocket expense accumulates separately for network and non-network services. The deductible and copayments (including, but not limited to, office visits copayments and prescription drug copayments) apply to the maximum out-of- pocket expense. Individual Plan Per contract year $6,350 $9,600 Family Plan Per contract year $12,700 The contract year family maximum out-of- pocket expense is met by adding the amount of covered health care expenses applied to the maximum out-of-pocket expense for all family members; however no one family member can contribute more than $6,350 the individual maximum out-of-pocket expense amount towards the contract year family maximum out-of- pocket expense. $19,200 The contract year family maximum out-of- pocket expense is met by adding the amount of covered health care expenses applied to the maximum out-of-pocket expense for all family members; however no one family member can contribute more than $9,600 the individual maximum out-of-pocket expense amount towards the contract year family maximum out-of- pocket expense. Medical Benefits Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Ambulance Ground $50 NO The level of coverage is the same as Tier 1 network provider The level of coverage is the same as Tier 1 network provider Air/Water Up to the maximum benefit of $3,000 per occurrence $50 NO The level of coverage is the same as Tier 1 network provider The level of coverage is the same as Tier 1 network provider Behavioral Health - Mental Health Inpatient * Unlimited days at a general hospital or a specialty hospital. 3020% YES 3020% YES 7060% YES Outpatient, Intermediate Inter- mediate Care Services* See Section 3.3 for details. 0% NO 0% NO 7060% YES In the office/in your home rendered by PCP ^ Includes individual and group sessions. $40 10 NO $40 10 for a member up to nineteen (19) years old NO 7060% YES $60 30 for a member nineteen (19) and older In the office/in your home rendered by Specialist Includes individual and group sessions. $65 30 NO $65 30 NO 7060% YES Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Behavioral Health – Substance Abuse Treatment Inpatient, Substance Abuse Chemical Dependency Treatment Facility * Detoxification – unlimited days per contract year. Residential Rehabilitation – unlimited days per contract year. 3020% YES 3020% YES 7060% YES Outpatient In a Substance Abuse Chemical Dependency Treatment facility (out- patientoutpatient), Intermediate Inter- mediate Care Services * See Section 3.3 for details. 0% NO 0% NO 7060% YES In the office/in your home rendered by PCP ^ $40 10 NO $40 10 for a member up to nineteen (19) years old NO 7060% YES $30 for a member nineteen (19) and older In the office/in your home rendered by Specialist $65 30 NO $65 30 NO 7060% YES Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Behavioral Health – Substance Abuse Treatment Methadone Maintenance Treatment $65 30 NO $65 30 NO 7060% YES Cardiac Rehabilitation Rehabili- tation Outpatient Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per covered episode. See Section 3 for details. 3020% YES 3020% YES 7060% YES Chiropractic Medicine In a Provider’s office^ 20 visits per contract year. $40 30 NO $60 50 NO 7060% YES Dental Care Hospital Emergency Room When services are due to accidental injury to sound natural teeth. $350 200 NO The level of coverage is the same as Tier 1 network provider The level of coverage is the same as Tier 1 network provider Services connected to dental care performed in Outpatient Facility * See Section 3.7 for benefit limitations. 3020% YES 3020% YES 7060% YES In an office (doctor or dentist) ^ When services are due to accidental injury to sound natural teeth. $65 30 NO $85 50 NO 7060% YES Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Dental Care Rendered to enrolled children under the age of 19 Oral Evaluations Two examinations per benefit year. Exams include: The initial examination or periodic examination or emergency oral evaluation when performed by a general dentist including diagnosis and charting per benefit year. 0% NO 0% NO 0% NO X-rays Single x-rays limited to four (4) per six (6) month period. .. 0% NO 0% NO 0% NO Bitewing limited to one (1) set per benefit year. 0% NO 0% NO 0% NO Limited to one full mouth series (FMX) or panorex per 60-60- month period. 0% NO 0% NO 0% NO X-rays other than those listed above 50% NO 50% NO 50% NO Cleanings Prophylaxis Two (2) cleanings per benefit year. 0% NO 0% NO 0% NO Fluoride Treatments Up to two (2) fluoride treatments for members under nineteen (19) years old per benefit year. 0% NO 0% NO 0% NO Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Dental Care Rendered to enrolled children under the age of 19 Cleanings (Prophy- laxis) Two (2) cleanings per benefit year. 0% NO 0% NO 0% NO Fluoride Treatments Up to two (2) fluoride treatments for members under nineteen (19) years old per benefit year. 0% NO 0% NO 0% NO Sealants For permanent molars only. Limited to one per tooth in a 24- 24-month period for members under nineteen (19) years old. 0% NO 0% NO 0% NO Space Maintainers 0% NO 0% NO 0% NO Palliative Treatment Minor treatment to relieve sudden, intense pain. 50% NO 50% NO 50% NO Fillings See Section for details. 50% NO 50% NO 50% NO Simple Extractions Removal of erupted tooth (non-non- surgical). 50% NO 50% NO 50% NO Denture Repairs and Relines/ Rebasing Full or partial dentures. Relines/Rebasing limited to once in a 60-month period. 50% NO 50% NO 50% NO Crowns & Onlays Predetermination is recommended. Replacement limited to once in a 60-month period. 50% NO 50% NO 50% NO Therapeutic Pulpoto- mies Limited to members under fourteen (14) years old. 50% NO 50% NO 50% NO Root Canal 50% NO 50% NO 50% NO Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Dental Care Rendered to enrolled children under the age of 19 Denture Repairs and Relines/ Rebasing Full or partial dentures. Relines/Rebasing limited to once in a 60-month period. 50% NO 50% NO 50% NO Crowns & Onlays Predetermination is recommended. Replacement limited to once in a 60-month period. 50% NO 50% NO 50% NO Therapeutic Pulpotomies Limited to members under fourteen (14) years old. 50% NO 50% NO 50% NO Root Canal Therapy – Anterior (front) Teeth 50% NO 50% NO 50% NO Root Canal Therapy - Posterior (back) Teeth back)Teeth 50% NO 50% NO 50% NO Non- Surgical Periodontal Services 50% NO 50% NO 50% NO Surgical Periodontal Services Predetermination is recommended. 50% NO 50% NO 50% NO Periodontal Maintenanc e Limited to two (2) services in a benefit year. 50% NO 50% NO 50% NO Fixed Bridges and Dentures Coverage for replacements limited to one (per tooth/unit) in a 60- month period Crowns over implants are considered a prosthodontic service. Predetermination is recommended. 50% NO 50% NO 50% NO Single Tooth Implant Coverage if placed as an alternative treatment to a conventional 3-unit 50% NO 50% NO 50% NO Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Dental Care Rendered to enrolled children under the age of 19 Periodontal Mainte- ▇▇▇▇▇ Limited to two (2) services in a benefit year. 50% NO 50% NO 50% NO Fixed Bridges and Dentures Coverage for replacements limited to one (per tooth/unit) in a 60-month period Crowns over implants are considered a prosthodontic service. Predetermination is recommended. 50% NO 50% NO 50% NO Single Tooth Implant Coverage if placed as an alternative treatment to a conventional 3- unit bridge Replacing only one missing tooth. Coverage for replacements limited to one (1) in a 60-month period. 50% NO 50% NO 50% NO Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Dental Care Rendered to enrolled children under the age of 19 Oral Surgery Services 50% NO 50% NO 50% NO General Anesthesia or IV Sedation Covered as a separate benefit when performed in conjunction with a covered oral surgery procedure(s). 50% NO 50% NO 50% NO Biopsies Limited to the biopsy and examination of oral tissue, soft or hard. 50% NO 50% NO 50% NO Occlusal (Night) guards Limited to one (1) every five (5) years. 50% NO 50% NO 50% NO Orthodontic Services (Braces) Predetermination is recommended. Only medically necessary braces are covered. 50% NO 50% NO 50% NO Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Diabetic Services Diabetic equipment/ supplies provided by a licensed medical supply provider (other than a pharmacy) 3020% YES 3020% YES 7060% YES Diabetic equipment/ supplies purchased at a retail pharmacy. See the Summary of Pharmacy Benefits for benefit limits and level of coverage. Office visits Podiatrist Services First routine visit of a contract year. See Section 3.8 for details. $0 NO $0 NO 60% YES Vision Care Service First routine eye exam of a contract year that includes a retinal eye exam. $0 NO $0 NO 60% YES Dialysis Services Inpatient/ Outpatient/ in your home 20% YES 20% YES 60% YES Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Diabetic Services Diabetic equipment/ supplies purchased at a retail pharmacy. See the Summary of Pharmacy Benefits for benefit limits and level of coverage. Office visits Podiatrist Services First routine visit of a contract year. See Section 3.8 for details. $0 NO $0 NO 70% YES Vision Care Service First routine eye exam of a contract year that includes a retinal eye exam. $0 NO $0 NO 70% YES Dialysis Services Inpatient/ Outpatient/ in your home 30% YES 30% YES 70% YES Durable Medical Equipment, Medical Supplies, Enteral Formu- la Formula and Food, and Prosthetic Devices Outpatient Durable Medical Equipment* Preauthorization recommended for certain services. See Section 3.9 for details. Must be provided by a licensed medical supply provider. 3020% YES 3020% YES 7060% YES Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Durable Medical Equipment, Medical Supplies, Enteral Formula and Food, and Prosthetic Devices Outpatient Medical Supplies* Must be provided by a licensed medical supply provider. 3020% YES 3020% YES 7060% YES Outpatient Prosthesis* Must be provided by a licensed medical supply provider. 3020% YES 3020% YES 7060% YES Enteral formula delivered through a feeding tube Must be sole source of nutrition. 3020% YES 3020% YES 7060% YES Enteral formula or food taken orally* See Section 3.9 for details. 3020% YES The level of coverage is the same as Tier 1 network provider The level of coverage is the same as Tier 1 network provider Hair Prosthesis (Wigs) Benefit is limited to the maximum benefit of $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 3020% YES The level of coverage is the same as Tier 1 network provider. The level of coverage is the same as Tier 1 network provider. Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Early Intervention Services (EIS) Early Intervention Services (EIS) For children from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% NO The level of coverage is the same as Tier 1 network provider. The level of coverage is the same as Tier 1 network provider. Education Asthma Management 0% NO 0% NO 70% YES Experimental/ Investiga-tional Services Coverage varies based on type of service. See Section 3.12. Hearing Hearing Exam^ $65 NO $85 NO 70% YES Diagnostic Testing 30% YES 30% YES 70% YES Hearing Aids A maximum benefit of $1,500 per ear per hearing aid for a member under 19; A maximum benefit of $700 per ear for a member 19 and older. 30% YES The level of coverage is the same as Tier 1 network provider. The level of coverage is the same as Tier 1 network provider. Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Hemophilia Services Outpatient Prescription drug coverage benefit level is based on type of service and site of service. See Summary of Pharmacy Benefits for details. Coverage varies based on type of hemophilia service. 30% YES 30% YES 70% YES Home Health Care In your home Intermittent skilled services when billed by a home health care agency. 30% YES 30% YES 70% YES Hospice Care Inpatient/ In your home When provided by an approved hospice care program. 30% YES 30% YES 70% YES Hospital Emergency Room Services Hospital Emergency Room See Section 8.0 – definition of Emergency $350 NO The level of coverage is the same as Tier 1. The level of coverage is the same as Tier 1. Service Service Type, Provider, or Place of Service Benefit Limit Tier 1 Network provider For a covered heath care service you pay: Tier 2 Network provider For a covered heath care service you pay: Non-network provider For a covered health care service you pay the difference between the charge amount and the allowance plus: Your copayment Does the deductible apply? Your copayment Does the deductible apply? Your copayment Does the deductible apply? Human Leukocyte Antigen Testing ^ Outpatient Hospital facility and designated free standing facilities See Section 3.18 for limitations. $75 NO $75 NO 70% YES Non- Hospital facility including in a Doctor’s office, urgent care center, and designated freestanding outpatient facilities $25 NO $75 NO 70% YES Infertility Outpatient/ in a doctor’s office Three (3) infertility treatment cycles will be covered per benefit year with a total of eight (8) infertility treatment cycles covered in a member’s lifetime. Prescription drug coverage benefit level is based on 20% YES 20% YES 20% YES Service Service Type, Provider: