Summary of Costs & Benefits

Footnotes to chart:

1. If lab services are provided on the same day as the office visit and a co-pay is collected for the visit, no additional co-pay will be collected. No co-pay will be collected when services are billed and provided as clinical preventive services. Exceptions: co-pay may be required for certain radiation oncology, vascular and pulmonary procedures and studies. Contact Customer Service for details.
2. One hour of therapy, no more than two times per week, when medically necessary. Includes in-home services.
3. With authorization, up to 30 days per enrollment year for adults (age 19+); up to 45 days per enrollment year for children under age 19; up to 150 days of residential treatment for children and adolescents.
4. Exclusive of drug maintenance programs.
5. Maximum of one rehabilitation program per year and three per lifetime. Detoxification and rehabilitation days count toward limit for mental health benefits.
6. Unless you are admitted to the hospital, in which case only the inpatient co-payment applies.
7. Prescription drug availability is limited to drugs prescribed by a Plan provider and covered as a Plan benefit. Availability of non-emergency prescriptions when out of the area is also limited. Over-the-counter medications and supplies are not covered. Retail vendor for prescriptions is Rite Aid Pharmacy.
8. Medicare-eligible enrollees showing evidence of current Part B payment do not have to pay the enrollment fee.
9. Outpatient treatment following the initial intake evaluation and testing is limited to a maximum of 36 sessions per cardiac event.

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