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Coverage Summary
Refer to your Policy for a full explanation of your benefits, the limitations on these benefits and the services that are not covered. The Policy also defines key terms used in the Policy and this Summary.
BENEFIT DESCRIPTION:
| Aggregate Lifetime Maximum Benefit |
$1,000,000.00 |
| Calendar Year Deductible |
$1,000.00 |
| Calendar Year Out of Pocket Maximum-In-Network |
$1,000.00 + Calendar Year Deductible |
Once you have met your calendar year deductible, all co-insurance that you pay for In-Network Covered Expenses and for prescription drugs counts towards your Out of Pocket Maximum, except for co-insurance paid for treatment of mental or nervous disorders, chemical or drug dependency, or Prescription Drugs used to treat chemical or drug dependency.
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| Out of Pocket Maximum-Out-of-Network |
None |
Out of Network facilities/providers may bill for balances over the CHIP payment level in addition to the deductible & co-insurance amount.
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| Percentage of Covered Expenses Paid by CHIP |
In-Network |
Out-of-Network |
Hospital, Physical Illness
Room & Board Allowance is
Average Semi-Private Room Rate |
80% |
60% |
| Prescription Drugs |
80% (All Covered Expenses paid at In-Network Rate) |
| Mental or Nervous Disorders |
50% * |
50% * |
| Chemical or Drug Dependency |
50% * |
50% * |
| All Other Types Of Covered Expenses |
80% |
60% |
*80/60 for Health Savings Accounts Qualified Plan Option
PRE-ADMISSION CERTIFICATION:
FOR ADMISSIONS TO HOSPITALS AND OTHER INPATIENT FACILITIES, CALL 1-800-451-7302.
FAILURE TO PRECERTIFY MAY RESULT IN A $500.00 REDUCTION IN BENEFITS PENALTY.
PAYMENT OF THIS PENALTY DOES NOT COUNT TOWARD YOUR OUT OF POCKET MAXIMUM
Call SPECIAL DELIVERY at 1-800-742-6457 as soon as you learn of your pregnancy to receive free educational materials and coupons that encourage good health practices. Let us help make your delivery a Special Delivery.
QUESTIONS: If you have any questions, please call 1-800-285-6477.
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