2013 Employee Benefits Guidebook - Administration Home

Ambulance Service
75% after deductible
Note: Pre-authorization with the Claims Administrator will be required for non-emergent transport.
Advanced Radiological Imaging (i.e.,
MRIs, MRAs, CAT Scans, PET Scans and
Nuclear Medicine)
75%
No deductible or copayment
will apply
Not Covered
Diagnostic X-ray & Lab Testing 100%
No deductible applies
Not Covered
Durable Medical Equipment 100%
Not Covered
No deductible or copayment
will apply
Home Health Care 75% after deductible Not Covered
Home Infusion Therapy 75% after deductible Not Covered
Hospice Care
75% after deductible
Not Covered
Note: A pre-authorization is required prior to services being rendered. Please see the Covered Charges section fo
Bereavement Counseling
75% after deductible
Not Covered
Mental Disorders and Substance Abuse Treatment
Inpatient Services Payable as any other Illness Not Covered
Outpatient Visits
100% after $10 copayment
Not Covered
No deductible applies
Morbid Obesity Benefit Payable as any other Illness Not Covered
more information regarding this benefit.
Nutritional Evaluation
Outpatient Short-Term Rehabilitation
Therapy and Chiropractic Services
Payable as any other Illness
3 visits per Calendar Year
maximum
100% after $20 copay per visit
No deductible applies
Not Covered
Not Covered
Includes: Cardiac Rehab, Physical Therapy, Speech Therapy, Occupational Therapy, Pulmonary Rehab,
Cognitive Therapy and Chiropractic services.
Multiple services provided on the same day constitute one visit, but a separate copayment will apply to the
services provided by each Physician.
Orthotics 75% after deductible Not Covered
Note: See Covered Charges section for details.
Prosthetics 100%
Not Covered
No deductible or copayment
will apply
Pregnancy *
Initial visit
(to confirm Pregnancy)
100% after $75 Specialist office
visit copayment
Not Covered
2013 Employee Benefit Guidebook
Updated August 2013