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Mental Heaith and Substanc�Abuse Rehabilitation T�eatment Benefits (cont'si)* <br /> Outpatient Serviccs PPO Non-PPO <br /> (coinsurence and/or deductibles not app6cable to OPX): <br /> Fiospital Payment Level: % % <br /> % % <br /> Physician Payment Level: $ $ <br /> Maximum Payable per Visit: <br /> Maximum Number of <br /> Visits per Calendar Year <br /> (combined PPO/Non-PPO): <br /> Program Deductible Applies: ❑ Yes ❑ No ❑ Yes ❑ No <br /> utpatient alen ar ear aximum combine ��07i�on-��� <br /> npat�ent& utpatient om ine i etime aximum: ($25,000 or$50,000)(combined PPO/Non-PPO) <br /> Well Care Benefits* <br /> PPO Non-PPO <br /> Weilness Care(all ages): ❑ Yes ❑ No ❑ Yes ❑ No <br /> Hosp. Payment Level: % % <br /> Phys. Payment Level: % o�o <br /> Office Visit Copay: $ $ <br /> Calendar Year Max: $ $ <br /> Program Ded.Applies: ❑ Yes ❑ No ❑ Yes ❑ No <br /> Well Child Care(to age 16): �Yes � No ❑Yes ❑ No <br /> Phys. Payment Level: % % <br /> Office Visit Copay: $ $ <br /> Calendar Year Max: $ $ <br /> Program Ded.Applies: ❑Yes ❑ No ❑ Yes ❑ No <br /> Benefits for Other Covered Services* <br /> General Payment Level: % <br /> utpatient erapies— ysica , ccupationa an peec — a en ar ear aximum: per t erapy <br /> (paid at General Payment Level;coinsurance not applicable to OPX) ($1,000[std], $2,000 or$3,000) <br /> Private Duty Nursing Maximum: per month 1,000[std], 2,000 or 3,000) <br /> (paid at General Payment Level;coinsurance not applicable to OPX) <br /> TMJ: ❑Yes ❑ No <br /> If yes; ❑$2,500 lifetime max(std) ❑$ per lifetime rr�ax (S1,000, $2,000 or$3,000) <br /> ❑$ per calendar year max ❑ No separate TMJ maximum <br /> (paid at General Payment Level; coinsurance not applicable to OPX) <br /> Other Provisions* <br /> andatory A itional urgical pinion Program: ❑ Yes ❑ No <br /> (applies to Hospital and Physician) If yes, benefit reduction: <br /> an atory utpatient urgery Program: ❑ Yes ❑ No <br /> (applies to Hospital and Physician) If yes, benefit reduction: <br /> e ica ervices Advisory Program: ❑ Yes ❑ o <br /> If yes, MSA Non-Compliance: $ ($amount benefits reduced) or % (%benefits reduced) <br /> OB-Precertification (r�rsct�mescer): ❑Yes ❑No Healthy Expectations: ❑ Yes ❑ No <br /> Healthy Expectations II: ❑ Yes ❑ No Outpatient Service Review: ❑ Yes ❑ No <br /> If no MSA, UR administered by an outside vendor: ❑ Yes ❑ No If yes, name of vendor <br /> enta ea t emica epen ency ti ization anagement e uction mount pplies) <br /> Note: If MSA applies, either Enhanced Utilization Management(EUM) or Network must be selected below. <br /> EUM: ❑Yes ❑ No If yes: � Inpatient Review Only(std) or ❑ Inpatient and Outpatient Review <br /> Network: ❑ Yes ❑ No If yes; Payment Levels: In-Network: % Out-of-Network: % <br /> mp oyee ssistance rogram es o <br /> imiting ge: epen ent ge: tu ent ge: <br /> Pre-existing Condition Waiting Period: ❑ Yes ❑ No If yes: <br /> Initial Waiver: ❑Yes (std) ❑ No Pre-existing Definition: ❑ 6 months (std) ❑ 3 months <br /> Employee Days: O 365(std) ❑ 270 ❑ 180; Dependent: ❑ 365 (std) ❑270 ❑ 180 <br /> Late Enrollees Accepted: ❑ Yes(std) ❑ No <br /> If yes, Employee Days: ❑ 546(std) ❑ 365 ❑ 270 C7 180; Dependent: ❑ 546 (std) ❑ 365 ❑ 270 � 180 <br /> Medical ecessity: ard Rider Reimbursement Provision: rJ es ❑ No <br /> Medicare overage: ❑ arve ut or ❑ ther please describe in ther pecial Provisions on page 4) <br /> An Independent Licensee of the Blue Cross and Blue Shield Association <br /> OB 3169 Rev.7/97 "Any variations other than those specified require Start-Up Committee Approval page 3 <br />