Extended Care and Rehabilitation [Complex Imaging Services See Definition [[All other] radiology services $300 per day up to $1500 per confinement; up to $3000 per year $300 per day up to $1500 per confinement; up to $3000 per year N/A See Tier 2 N/A See Tier 2 $500 per day up to $3000 per confinement; up to $5000 per year $500 per day up to $3000 per confinement; up to $5000 per year $100 per procedure] $75 per procedure] Laboratory Services NONE $30 per visit Emergency Room Visit Outpatient Surgery Inpatient Surgery Coinsurance (See definition below) Preventive Care Prescription Drugs [Generic Drugs] [Preferred Drugs] [Non-Preferred Drugs] Durable Medical Equipment [Maximum Out of Pocket Per [Calendar] [Plan] Year (See definition below) Per Member Per Covered Family (Use above for separate accumulation.) [Maximum Out of Pocket Per [Calendar] [Plan] Year (See definition below) Per Member $50 $100 $250 NONE N/A See Tier 2 N/A See Tier 2 $2,000 $4,000 $2,000 $4,000 $100 $250 $500 NONE 50% [10%] [20%] [50%] 50% $4,400 $8,800] $6,850 or amount permitted by 45 C.F.R. 156.130
For cases that are treated in a facility. For cases taken to the operating room –dental services are provided for patient with a medical condition covered by this Policy which requires this admission as in-patient or out-patient. Prior authorization is required. General anesthesia and outpatient facility charges for dental services are covered Dental services rendered in these settings by a dentist not on staff are considered separately Office visit for observation – (during regular hours) no other service performed Drugs Therapeutic parenteral drug Single administration Two or more administrations - not to be combined with single administration Other drugs and/or medicaments – by report Application of desensitizing medicament – per visit Occlusal guard – for treatment of bruxism, clenching or grinding Athletic mouthguard covered once per year Occlusal adjustment Limited - (per visit) Complete (regardless of the number of visits), once in a lifetime Odontoplasty Internal bleaching ] Note to carriers: the above Dental benefits provision is variable and may be deleted if a stand-alone dental plan is bought. If the provision is deleted include the following heading such that the under age 6 provision would be part of the Dental Care and Treatment provision. [Additional benefits for a Child under age 6] For a [Member] who is severely disabled or who is a Child under age 6, We cover: general anesthesia and Hospitalization for dental services; and dental services rendered by a dentist regardless of where the dental services are provided for a medical condition covered by the Contract which requires Hospitalization or general anesthesia. (k) TREATMENT FOR TEMPOROMANDIBULAR JOINT DISORDER (TMJ) The following services are covered when rendered by a [Network] Practitioner [upon prior Referral by a [Member's] Primary Care Provider]. We cover services and supplies for the Medically Necessary and Appropriate surgical and non-surgical treatment of TMJ in a [Member]. However, with respect to coverage of TMJ We do not cover any services or supplies for orthodontia, crowns or bridgework. (l) THERAPEUTIC MANIPULATION The following services are covered when rendered by a [Network] Practitioner [upon prior Referral by a [Member's] Primary Care Provider ]. We limit what We cover for therapeutic manipulation to 30 visits per