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Broadway Services Inc. Plan — 2020-2021

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EHP Network ProviderOut of Network Provider
Acupuncture
Medically necessary services for anesthesia, pain control, and therapeutic purposes$25 co-pay, then 100% of allowed amount ($1000 annual maximum for all networks combined)70% of allowed benefit; deductible applies ($1000 annual maximum for all networks combined)
Allergy Tests & Procedures
Allergy tests100% of allowed amount70% of allowed benefit; deductible applies
Desensitization materials and serum100% of allowed amount70% of allowed benefit; deductible applies
Ambulance Transportation
Medically necessary ground transport100% of allowed amount100% of allowed benefit; deductible applies
Medically necessary air transportNot CoveredNot Covered
Biofeedback
BiofeedbackNot CoveredNot Covered
Chemo & Radiation Therapy
Physician visit100% of allowed amount70% of allowed benefit; deductible applies
Materials and treatment100% of allowed amount70% of allowed benefit; deductible applies
Chiropractic Care
Chiropractor restricted to initial exam, x-rays, and spinal manipulations$25 co-pay, then 100% of allowed amount ($1000 annual maximum for all networks combined)70% of allowed benefit; deductible applies ($1000 annual maximum for all networks combined)
Chiropractor with PT privileges (physical therapy services)Refer to Therapy sectionRefer to Therapy section
Dialysis
Medically necessary services100% of allowed amount 70% of allowed benefit; deductible applies
Durable Medical Equipment
Breast pumps (standard) and related supplies100% of allowed amount (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Contraceptive devicesNot CoveredNot Covered
Custom DME, including custom wheelchairs100% of allowed amount (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Custom-molded orthotics100% of allowed amount (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Insulin pumps, Continuous Glucose Monitor and related supplies100% of allowed amount 70% of allowed benefit; deductible applies
Hearing aidsNot CoveredNot Covered
Non-custom medical equipment and supplies100% of allowed amount70% of allowed benefit; deductible applies
Prosthetic devices100% of allowed amount (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Blood Pressure Cuff100% of allowed amount70% of allowed benefit; deductible applies
Emergency Services
Emergency care (facility fees)$150 co-pay, then 100% of allowed amount (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage$150 co-pay, then 100% of allowed benefit; deductible waived (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage
Emergency care (professional fees)100% of allowed amount100% of allowed benefit; deductible waived
Home Health Services
Medically necessary services100% of allowed amount (40 visits per year maximum for all networks combined; pre-authorization required)70% of allowed benefit; deductible applies (40 visits per year maximum for all networks combined; pre-authorization required)
Home infusion therapy100% of allowed amount 70% of allowed benefit; deductible applies
Hospice Care
Inpatient and home hospice100% of allowed amount (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Hospital Care
Inpatient care including newborn nursery care; NICU (facility fees)100% of allowed amount (semi-private, unless private room is medically necessary; pre-authorization required)$100 co-pay per admission, then 70% of allowed benefit; deductible applies (semi-private, unless private room is medically necessary; pre-authorization required)
Inpatient care (professional fees)100% of allowed amount70% of allowed benefit; deductible applies
Skilled nursing/rehabilitation facility100% of allowed amount (120 days per year maximum for all networks combined; pre-authorization required)70% of allowed benefit; deductible applies (120 days per year maximum for all networks combined; pre-authorization required)
Short-term acute rehabilitation100% of allowed amount (120 days per year maximum for all networks combined; pre-authorization required)70% of allowed benefit; deductible applies (120 days per year maximum for all networks combined; pre-authorization required)
Observation care (facility fees)$135 co-pay, then 100% of allowed amount (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage$135 co-pay, then 100% of allowed benefit; deductible waived (if admitted, ER co-pay waived); see Inpatient Facility Care for coverage
Observation care (professional fees)100% of allowed amount100% of allowed benefit; deductible waived
Outpatient surgery & ambulatory surgical center (facility fees)100% of allowed amount (includes freestanding surgical centers)70% of allowed benefit; deductible applies (includes freestanding surgical centers)
Outpatient surgery & ambulatory surgical center (professional fees)100% of allowed amount70% of allowed benefit; deductible applies
Hyperbaric Oxygen Therapy
Medically necessary services100% of allowed amount (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Immunizations
Preventive immunizations for communicable diseases100% of allowed amount70% of allowed benefit; deductible applies
Travel immunizations100% of allowed amount70% of allowed benefit; deductible applies
Infusion Therapy
Home infusion therapy100% of allowed amount (pre-authorization required)70% of allowed benefit; deductible applies (pre-authorization required)
Outpatient infusion therapy100% of allowed amount70% of allowed benefit; deductible applies
Injections
Injections100% of allowed amount70% of allowed benefit; deductible applies
Materials and serum100% of allowed amount70% of allowed benefit; deductible applies
Laboratory
Laboratory tests including pathology100% of allowed amount70% of allowed benefit; deductible applies
Mental Health & Substance Use Disorder Services
Outpatient mental health care (facility fees)100% of allowed amount70% of allowed benefit; deductible applies
Outpatient mental health care (professional fees)$15 co-pay, then 100% of allowed amount70% of allowed benefit; deductible applies
Inpatient mental health care (facility fees)100% of allowed amount (semi-private, unless private room is medically necessary; pre-authorization required)$100 co-pay per admission, then 70% of allowed benefit; deductible applies (semi-private, unless private room is medically necessary; pre-authorization required)
Inpatient mental health care (professional fees)100% of allowed amount70% of allowed benefit; deductible applies
Outpatient substance use disorder care (facility fees)100% of allowed amount70% of allowed benefit; deductible applies
Outpatient substance use disorder care (professional fees)$15 co-pay, then 100% of allowed amount70% of allowed benefit; deductible applies
Inpatient substance use disorder care (facility fees)100% of allowed amount (semi-private, unless private room is medically necessary; pre-authorization required)$100 co-pay per admission, then 70% of allowed benefit; deductible applies (semi-private, unless private room is medically necessary; pre-authorization required)
Inpatient substance use disorder care (professional fees)100% of allowed amount70% of allowed benefit; deductible applies
Intensive outpatient program$15 co-pay, then 100% of allowed amount70% of allowed benefit; deductible applies
Partial hospital facility services$15 co-pay, then 100% of allowed amount70% of allowed benefit; deductible applies
Medication management$15 co-pay, then 100% of allowed amount70% of allowed benefit; deductible applies
Mental health testing and procedures$15 co-pay, then 100% of allowed amount70% of allowed benefit; deductible applies
Methadone Treatment
Medically necessary outpatient care$15 co-pay, then 100% of allowed amount70% of allowed benefit; deductible applies
Nutritional Counseling
Medically necessary services$25 co-pay, then 100% of allowed amount (limited to one initial consultation and one follow-up visit for all networks combined)70% of allowed benefit; deductible applies (limited to one initial consultation and one follow-up visit for all networks combined)
Office Visits for Treatment of Illness or Injury
Primary care office visit only (Adult)$15 co-pay, then 100% of allowed amount70% of allowed benefit; deductible applies
Primary care office visit (Pediatric: age 19 and under)$15 co-pay, then 100% of allowed amount70% of allowed benefit; deductible applies
Primary care office visit only (GYN)$15 co-pay, then 100% of allowed amount70% of allowed benefit; deductible applies
Specialty care office visit only (Adult & Pediatric)$25 co-pay, then 100% of allowed amount70% of allowed benefit; deductible applies
Treatment and diagnostic services in the office100% of allowed amount70% of allowed benefit; deductible applies
Preventive Services
Preventive exam (PCP, GYN and Well Child care)$15 co-pay, then 100% of allowed amount70% of allowed benefit; deductible applies
Diagnostic services for preventive exam100% of allowed amount70% of allowed benefit; deductible applies
Routine preventive screenings: mammogram, colonoscopy, PAP test, etc.100% of allowed amount70% of allowed benefit; deductible applies
Routine hearing exams100% of allowed amount70% of allowed benefit; deductible applies
Private Duty Nursing
Private Duty NursingNot CoveredNot Covered
Radiology Procedures
Advance imaging including MRI, CT and PET scans100% of allowed amount70% of allowed benefit; deductible applies
All other imaging studies; including X-Ray and Ultrasound100% of allowed amount70% of allowed benefit; deductible applies
Reproductive Health
Physician office visits (prenatal care only)Routine prenatal visits and all other prenatal visits covered at 100% of allowed amount70% of allowed benefit; deductible applies
Infertility treatmentNot CoveredNot Covered
Birthing centers (facility fees)100% of allowed amount70% of allowed benefit; deductible applies
Birthing centers (professional fees)100% of allowed amount70% of allowed benefit; deductible applies
Inpatient maternity care and delivery; newborn nursery care; NICU (facility fees)100% of allowed amount (semi-private, unless private room is medically necessary; pre-authorization required)$100 co-pay per admission, then 70% of allowed benefit; deductible applies (semi-private, unless private room is medically necessary; pre-authorization required)
Inpatient maternity care and delivery; newborn nursery care; NICU (professional fees)100% of allowed amount70% of allowed benefit; deductible applies
Interruption of pregnancy100% of allowed amount (pre-authorization required; life of mother, rape, or incest only)70% of allowed benefit; deductible applies (pre-authorization required; life of mother, rape, or incest only)
Female sterilization (professional services for surgery, anesthesia and related pathology)100% of allowed amount70% of allowed benefit; deductible applies
Male sterilization (professional services for surgery, anesthesia and related pathology)100% of allowed amount70% of allowed benefit; deductible applies
Surgical Procedures
Surgical treatment for morbid obesityNot CoveredNot Covered
Primary care office surgical procedures100% of allowed amount 70% of allowed benefit; deductible applies
Specialist care office surgical procedures100% of allowed amount 70% of allowed benefit; deductible applies
Outpatient surgery (including freestanding surgical centers) (facility fees)100% of allowed amount 70% of allowed benefit; deductible applies
Outpatient surgery (including freestanding surgical centers) (professional fees)100% of allowed amount 70% of allowed benefit; deductible applies
Inpatient surgery (facility fees)100% of allowed amount (semi-private, unless private room is medically necessary; pre-authorization required)$100 co-pay per admission, then 70% of allowed benefit; deductible applies (semi-private, unless private room is medically necessary; pre-authorization required)
Inpatient surgery (professional fees)100% of allowed amount 70% of allowed benefit; deductible applies
Therapy
Habilitative services for children under the age of 19Not CoveredNot Covered
Physical therapy/occupational therapy medically necessary services100% of allowed amount (60 visits per year maximum for all networks combined)70% of allowed benefit; deductible applies (60 visits per year maximum for all networks combined)
Speech therapy (non-developmental medically necessary services)100% of allowed amount (30 visits per year maximum for all networks combined; pre-authorization required)70% of allowed benefit; deductible applies (30 visits per year maximum for all networks combined; pre-authorization required)
Pulmonary rehabilitation100% of allowed amount70% of allowed benefit; deductible applies
Cardiac rehabilitation100% of allowed amount70% of allowed benefit; deductible applies
Vision therapyNot CoveredNot Covered
Urgent Care Center
Physician visit$15 co-pay, then 100% of allowed amount70% of allowed benefit; deductible applies
Diagnostic services and treatment100% of allowed amount70% of allowed benefit; deductible applies
Revised
September 1, 2022
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