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Hospital Services

MEDICAL, MENTAL HEALTH AND CHEMICAL DEPENDENCY
PPO PLAN LOW OPTION PLAN 1
Network
Provider 2
Non-
Network Provider
Out Of Area
(For participants who live over 25 miles outside the PPO service area of 2 providers) 3 4
Network Provider 2 Non-
Network Provider 3
Hospital Services
Emergency Room 85%
after $50 copay (copay is waived if admitted; hospital admission copay applies)
70% 18
after $50 copay (copay is waived if admitted; hospital admission copay applies)
80% 18
after $50 copay (copay is waived if admitted; hospital admission copay applies)
70%
after $50 copay (copay is waived if admitted; hospital admission copay applies)
60% 18
after $50 copay (copay is waived if admitted; hospital admission copay applies)
Inpatient
Services 16 17
85%
after $100 copay/admission
70%
after $100 copay/admission
80%
after $100 copay/admission
70%
after $100 copay/admission
60%
after $100 copay/admission
Outpatient
Services 11  17
85% 11 70% 80% 70%11 60%
Outpatient Lab Work
and X-rays
85% 11 70% 80% 70% 11 60%
Skilled Nursing Facility 17  23 85%
after $100 copay/admission
70%
after $100 copay/admission
80%
after $100 copay/admission
70%
after $100 copay/admission
60%
after $100 copay/admission


1. For COBRA participants and Extended Coverage participants only.

2. Benefits for services received from a network provider will be paid based on the contracted rate.

3. Benefits for services received from non-network and out-of-area providers will be paid based on reasonable and customary (R&C) allowances. The participant is responsible for any amount over the R&C.

4. The participant must contact the Fund office to determine if the provider qualifies for the out-of-area benefit. If the provider is approved, the participant is responsible for filing claims with the Fund to receive benefit reimbursement.

11. See Preventive Care Benefits Services, page 10. Some or all of the services in this section may be covered under the Preventive Care Service Benefits, payable at 100%, no deductible, when seen by a network provider.

12. Includes prenatal care, delivery and postnatal care of a physician-delivered baby.

16. Includes semi-private room and board within plan limits and ancillary services.

17. Preauthorization review is required for all inpatient and outpatient treatment facilities, such as partial hospitalization, residential day treatment and intensive outpatient programs.

18. Emergency room services may qualify for network coinsurance if emergency care definition is met. See SPD page 48 for definition.

23. Please have your provider contact the Fund's Utilization Administrator (Anthem Blue Cross) to facilitate your care through Case Management Intervention. On the backside of your Medical ID card, you will find the phone number for Preauthorization or Pre-Service Review.