[Telemedicine Visits [E-Visits [Virtual Visits [$15] Copayment / visit [$15] Copayment / visit [$15] Copayment / visit N/A] N/A] N/A] Preventive Care; [$0] Copayment / visit [Deductible/Coinsurance] Surgery Inpatient $0 Copayment Deductible/Coinsurance Outpatient Visit [$15] Copayment Deductible/Coinsurance Pre-Admission Testing [$15] Copayment Deductible/Coinsurance Second Surgical Opinion [$15] Copayment Deductible/Coinsurance SCHEDULE OF COVERED SERVICES AND SUPPLIES AND COVERED CHARGES (Continued) SERVICES [NETWORK] [NON-NETWORK] Specialist Services [$15] Copayment Deductible/Coinsurance Therapy Services NOTE: Limited Benefits. Refer to the Covered Services and Supplies and Covered Charges sections [$15] Copayment Deductible/Coinsurance [Complex Imaging Services [$30 Copayment] Deductible/Coinsurance] [All other] Diagnostic Services Inpatient $0 Copayment Deductible/Coinsurance Outpatient Visit [$15] Copayment Deductible/Coinsurance Rehabilitation Services NOTE: [Non-Network] benefits LIMITED. Refer to the Covered Charges section Subject to the Hospital Inpatient Copayment; waived if admission immediately preceded by inpatient hospitalization Deductible/Coinsurance Center NOTE: benefits LIMITED. Refer to the Covered Charges section $0 Copayment Deductible/Coinsurance
be approved for its stated purpose by Medicare. A Facility is not a Birthing Center, for the purpose of this Contract, if it is part of a Hospital. BOARD. The Board of Directors of the New Jersey Small Employer Health Benefits Program. CALENDAR YEAR. Each successive twelve-month period starting on January 1 and ending on December 31. CASH DEDUCTIBLE or DEDUCTIBLE. The amount of Covered Charges that a [Member] must pay before this Contract pays any benefits for such charges. Cash Deductible does not include Coinsurance, Copayments, and Non-Covered Services and Supplies and Non-Covered Charges. See the Cash Deductible section of this Contract for details. CHURCH PLAN. Has the same meaning given that term under Title I, section 3 of Pub.L.93-406, the “Employee Retirement Income Security Act of 1974” COINSURANCE. The percentage of Covered Services or Supplies or the percentage of Covered Charges, as applicable, that must be paid by a [Member]. Coinsurance does not include the Cash Deductible, Copayments, or Non-Covered Services and Supplies and Non-Covered Charges. [COMPLEX IMAGING SERVICES. Any of the following services: Computed Tomography (CT), Computed Tomography Angiography (CTA), Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiogram (MRA), Magnetic Resonance Spectroscopy (MRS) Positron Emission Tomography (PET), Nuclear Medicine including Nuclear Cardiology.] CONTRACT. This contract, including the application and any riders, amendments or endorsements, between the Contractholder and Us. CONTRACTHOLDER. Employer or organization which purchased this Contract. COPAYMENT. A specified dollar amount which [Member] must pay for certain Covered Services or Supplies or Covered Charges. NOTE: The Emergency Room Copayment, if applicable, must be paid in addition to any other Copayments, Cash Deductible, and Coinsurance.
Services or supplies provided by one of the following [members] of the Employee's family: spouse, child, parent, in-law, brother, sister or grandparent. Services or supplies furnished in connection with any procedures to enhance fertility which involve harvesting, storage and / or manipulation of eggs and sperm. This includes, but is not limited to the following: a) procedures: in vitro fertilization; embryo transfer; embryo freezing; and Gamete intra-fallopian Transfer (GIFT) and Zygote Intrafallopian Transfer (ZIFT); donor sperm, surrogate motherhood and b) Prescription Drugs not eligible under the Prescription Drugs section of the Policy and c) ovulation predictor kits. See also the separate Exclusion addressing sterilization reversal. Except as otherwise stated in the Hearing Aids and Newborn Hearing Screening provisions, services or supplies related to hearing aids and hearing examinations to determine the need for hearing aids or the need to adjust them. Services or supplies related to herbal medicine. Services or supplies related to hypnotism. Services or supplies necessary because the [Member] engaged, or tried to engage, in an illegal occupation or committed or tried to commit an indictable offense in the jurisdiction in which it is committed, or a felony. Exception: As required by 29 CFR 2590.702(b)(2)(iii) this exclusion does not apply to injuries that result from an act of domestic violence or to injuries that result from a medical condition. Except as stated below, Illness or Injury, including a condition which is the result of disease or bodily infirmity, which occurred on the job and which is covered or could have been covered for benefits provided under workers' compensation, employer's liability, occupational disease or similar law. Exception: This exclusion does not apply to the following persons for whom coverage under workers’ compensation is optional unless such persons are actually covered for workers’ compensation: a self-employed person or a partner of a limited liability partnership, members of a limited liability company or partners of a partnership who actively perform services on behalf of the self-employed business, the limited liability partnership, limited liability company or the partnership. Local anesthesia charges billed separately if such charges are included in the fee for the Surgery. Membership costs for health clubs, weight loss clinics and similar programs. Services and supplies related to marriage, career or financial counseling, sex therapy or family therapy, and related services.