Page 17 - The Legacy School Benefit Booklet 2021-2022

BlueChoice HMO HSA/HRA Silver 3000 ON/OFF SHOP Summary of Benefits

Services In-Network You Pay 1
DIAGNOSTIC SERVICES​
Labs 7​
■ LabCorp​ Deductible, then $25 per visit​
■ Hospital (preauthorization required)​ Deductible, then $50 per visit​
X-ray 7​
■ Non-Hospital/Freestanding Facility​ Deductible, then $50 per visit​
■ Hospital (preauthorization required)​ Deductible, then $100 per visit​
Imaging 7​
■ Non-Hospital/Freestanding Facility​ Deductible, then $250 per visit​
■ Hospital (preauthorization required)​ Deductible, then $500 per visit​
SURGERY AND HOSPITALIZATION—(Members are responsible for both physician and facility fees)​
Outpatient Surgery (Non-Hospital)​
■ Facility​ Deductible, then $300 per visit​
■ Physician​ Deductible, then $50 per visit​
Outpatient Surgery (Hospital)​
■ Facility​ Deductible, then $400 per visit​
■ Physician​ Deductible, then $50 per visit​
Inpatient Surgery and Hospital Services​
■ Facility​ Deductible, then $500 per day (5 day maximum payment per admission)​
■ Physician​ Deductible, then $50 per visit​
HOSPITAL ALTERNATIVES​
Home Health Care​ No charge* after deductible​
Hospice​ No charge* after deductible​
Skilled Nursing Facility​ Deductible, then $50 per day​
(limited to 100 days/benefit period)​
MATERNITY​
Preventive Prenatal and Postnatal Office Visits​ No charge*​
Delivery and Facility Services​ Deductible, then $500 per day (5 day maximum payment per admission)​
Artificial and Intrauterine Insemination 5,8​ Deductible, then $25 per visit​
In Vitro Fertilization Procedures 5,8​ Not covered​
MENTAL HEALTH AND SUBSTANCE USE DISORDER—(Members are responsible for both physician and facility fees)​
Office Visits​ Deductible, then $25 per visit​
Outpatient Services​
■ Facility​ Deductible, then $50 per visit​
■ Physician​ Deductible, then $50 per visit​
Inpatient Services​
■ Facility​ Deductible, then $500 per day (5 day maximum payment per admission)​
■ Physician​ Deductible, then $50 per visit​
MEDICAL DEVICES AND SUPPLIES​
Durable Medical Equipment​ Deductible, then 25% of Allowed Benefit​
Hearings Aids​ Deductible, then 25% of Allowed Benefit​
(limited to one hearing aid per​
hearing-impaired ear every 36 months)​

SUM5150-1P (9/20) ■ MD ■ 2021 2-50 ACA Compliant (Can be sold as HDHP)​