Summary Plan Description

Physician Services

90% Network and 80% Non-Network

Benefits are provided for services and supplies provided by a licensed physician covered under this plan. Each patient is responsible for the office visit copayment(s) when an office visit is billed. Covered services include:

  • Physician visits.
  • An eye examination (including refraction) performed in conjunction with a medical condition such as diabetes, glaucoma and cataracts.
  • Hearing exams to determine the presence of an illness, injury or other hearing loss. The plan covers exams by physicians and audiologists.
  • Injectable legend drugs administered in a physician's office that are used to treat a covered condition.
  • Surgical procedures (please see below).
  • Adult immunizations required for certain exposures.
  • Chemotherapy, radium therapy and other radioactive-type therapies.
  • Allergy testing up to an annual maximum of 12 blood and 60 skin tests.
  • Antigen and allergy vaccines or serums.

Surgery

Benefits are provided for covered services performed by a physician in:

  • A physician's office.
  • An approved outpatient or same-day surgical center.
  • An approved ambulatory surgical center.
  • An approved hospital.

The plan uses accepted professional guidelines as developed by the American Medical Association (AMA) and other professional and governmental entities to determine the maximum allowed fee for specific surgical procedures, assistant surgeon's fees, post-operative care, and multiple surgical procedures. When two or more procedures are performed during one operation, secondary procedures may be reimbursed at reduced amounts. Additional surgical procedures that are performed as a part of the total procedure or are "incidental" to the procedure, and pre- and post-operative care by the operating surgeon (except to the extent it is already included in the surgeon's fee) are not covered.

This plan does not cover general anesthesia or the use of a hospital, ambulatory surgical center or other surgical facility for surgical procedures commonly and primarily performed in a clinic or physician's office.