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Health Fund

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Physician 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
Physician Services
Doctor's Office Visit 9 85% 11 70% 80% 70% 11 60%
Periodic Health Assessment Covered under Wellness
Benefits 10 11
Covered under Wellness
Benefits 10
Covered under Wellness
Benefits 10
Not covered 11 Not covered
Well Baby Care 85% 11 70% 80% 70% 11 60%
Childhood Wellness Visits including Immunizations:
  • Through age 6
  • Ages 7 and older
85%11
Covered under Wellness
Benefits
10 11
70%
Covered under Wellness
Benefits
10
80%
Covered under Wellness
Benefits
10
70%
Not covered 11
60%
Not covered
Adult
Immunizations
Covered under Wellness
Benefits
10 11
Covered under Wellness
Benefits
10
Covered under Wellness
Benefits
10
Not covered 11 Not covered
Maternity Care 12 85% 11 70% 80% 70% 11 60%
Inpatient/
Outpatient Physician Services
85% 13 70% 80% 70% 13 60%
Inpatient Routine Nursery Visits and Room and Board 14 85% 70% 80% 70% 60%
Other Physician Services 85% 11 70% 80% 70% 11 60%
Surgery 15 85% 70% 80% 70% 60%

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.

9. Includes lab work and X-rays.

10. See Wellness Benefits, page 12.

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.

13. Non-network anesthesiologists, radiologists and pathologists are payable at 85% of R&C under the PPO plan or 70% of R&C under the Low Option plan, if services are rendered at a network facility by a network physician.

14. Inpatient hospital copay applies to the facility fees associated with the baby's facility charges.

15. Assistant surgeons will be considered at a reduced benefit level that is equal to 20% of the surgeon's contract or R&C allowances.