HMO POS PPO - Arkansas Blue Cross and Blue Shield

6 HMO/POS Benefit SummaryIN-NETWORKHMO & POSOUT-OF-NETWORKPOS ONLYDURABLE MEDICAL EQUIPMENT-$10,000 MAX PER MEMBER PER CONTRACT20% Coinsurance 30% after DeductiblePROSTHETICS- $15,000 ANNUAL MAXIMUM 20% Coinsurance 30% after DeductibleDIABETIC EQUIPMENT AND INSULIN PUMPSUPPLIES (Diabetic supplies not for insulin pump are 20% Coinsurance 30% after Deductiblecovered by the prescription drug card)OSTOMY SUPPLIES 10% Coinsurance 30% after DeductibleHOME HEALTH SERVICES-120 VISITS PER MEMBERPER CONTRACT YEAR0% Coinsurance 30% after DeductibleHOME IV DRUGS/SOLUTIONS 10% Coinsurance 30% after DeductibleINJECTABLE MEDICATIONS-Medications when covered Office Visit Copayby Health Advantage-Subject to exclusions and limitations May Apply30% after DeductibleINFERTILITY SERVICES**Infertility Counseling $25 Copay 30% after DeductibleInfertility Testing10% Coinsurance(outpatient Surgery Copay may apply)30% after DeductibleSKILLED NURSING FACILITY-$250 Copay +Limited to 60 days Per Member Per Contract Year10% Coinsurance30% after DeductibleHospice Care (must be approved by Health Advantage) 20% 30% after DeductibleTMJ- Covered when diagnosed as medical condition Applicable CopayLimited to $500 Lifetime Maximum per Member10% Coinsurance30% after DeductibleOrgan Transplant Services- must be approved by Health$250 per admissionAdvantage (2 transplants per Member per Lifetime) – kidneyNOT COVEREDand cornea transplants are not subject to prior approval.Routine Vision Exam 1 every 24 months $25 Copay NOT COVEREDPreventive Dental (cleanings and exam) 2 per person peryear (see page 5 for complete list of services)$25 Copay NOT COVERED*The Summary Plan Description (SPD) can be viewed online at www.arbenefits.org under the Benefits Librarysection, or you may contact Employee Benefits Division for a paper copy.**Treatment for infertility is not a covered benefit – benefits cover testing and counseling only.NOTE: Out-of-Network Deductible, Copayment and Coinsurance amounts do not apply to the In-Network AnnualCoinsurance Limit. Annual Coinsurance Limits are calculated on a fulfillment basis, not aggregate.Expenses incurred for services that exceed benefit limits are not applied to the Annual Coinsurance Limit.For In-Network benefits, services must be performed, arranged or authorized by the Primary Care Physician, exceptfor Emergency Care. The Member may be responsible for the difference between Billed Charges and AllowableCharges for services covered at the Out-of-Network benefit level if the provider does not participate with anyBlue Cross plan nationwide.To determine when and if providers have joined the HMO network visit the provider directories (updated nightly)found at www.HealthAdvantage-hmo.com. By using the providers listed in the directory, members will receive thehighest level of benefits from their health plan.