Medical Insurance
Share Traditional Plan
In-Network
Share High Deductible Health Plan
In-Network
Diagnostic Tests — Minor * For preventive lab , x-ray and diagnostics , refer to the preventive care services category
Diagnostic Tests — Major CT , PET , MRI , MRA , etc .
100 % covered , deductible does not apply 20 % after deductible has been met
20 % after deductible has been met 20 % after deductible has been met
Ostomy Supplies 20 % after deductible has been met 20 % after deductible has been met
Pharmaceutical Products — Outpatient This includes medications administered in an outpatient setting , in the Physician ’ s Office or in a covered person ’ s home .
Physician Fees for Surgical and Medical Services
Pregnancy — Maternity Services
Durable Medical Equipment ** See Master Policy for benefit limits
Chiropractic Services ( up to 20 visits per calendar year )
Outpatient Rehab / Habilitative Therapy : Physical , Speech , Occupational » See Master Policy for details
Scopic Procedures — Outpatient Diagnostic and Therapeutic » Colonoscopy » Sigmoidoscopy » Endoscopy For preventive scopic procedures , refer to the preventive care services category .
Skilled Nursing Facility / Inpatient Rehabilitation Facility Services Preauthorization required
20 % after deductible has been met 20 % after deductible has been met
20 % after deductible has been met 20 % after deductible has been met
Depending upon where the covered health service is provided , benefits will be the same as those stated under each covered health service category in this benefit summary .
Depending upon where the covered health service is provided , benefits will be the same as those stated under each covered health service category in this benefit summary .
For services provided in the Physician ’ s Office , a Copayment will only apply to the initial office visit .
20 % after deductible has been met 20 % after deductible has been met
$ 15 copayment per visit $ 15 after deductible has been met
$ 40 copayment after deductible $ 25 after deductible has been met
20 % after deductible has been met 20 % after deductible has been met
20 % after deductible has been met 20 % after deductible has been met
Surgery — Outpatient 20 % after deductible has been met 20 % after deductible has been met
Therapeutic Treatments — Outpatient » Dialysis » Intravenous chemotherapy or other intravenous infusion therapy » Radiation oncology
Transplantation Services
Vision Examinations 1 exam per plan year
20 % after deductible has been met 20 % after deductible has been met
Depending upon where the Covered Health Service Category is in this Benefit Summary For network benefits , services must be received at a designated facility .
Preventative eye exams covered 100 %, all other eye exams $ 40 copay
Depending upon where the Covered Health Service Category is in this Benefit Summary For network benefits , services must be received at a designated facility .
Preventative eye exams covered 100 %, all other eye exams $ 25 after deductible has been met
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