Page 7 - PA_PPO_Member_Kit

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What’s Covered?
We Broadly Cover Preventive and Medically Necessary Health Care Services and Supplies if:
• We approve them in our system
• Your doctor approves them (HMO plan only)
• It is required in an emergency or urgent care scenario
In General, We Do Not Cover Any Service That is Not Medically Necessary, Such as:
• Cooking, bathing and other activities of daily living
• Long-term care
• Private-duty nursing
• Private rooms
• Cosmetic surgery, such as breast enhancement (unless mastectomy has been performed)
• Liposuction
• Experimental services
• Investigative services
• HMO plans only – we do not cover any care that is not approved by your PCP
(except emergency care, out-of-area urgent care and OB/GYN care)
: For a complete list of covered and non-covered services, see your Subscriber Contract and Riders
or your Health Insurance Policy and your Summary of Benefits and Coverage. You can also log in at
to see if a service is covered and what your cost-sharing amount might be. Log in and choose
Procedure Lookup. Then enter the procedure code given by your doctor.
Cost-Sharing Responsibilities
There are three main types of costs that you may need to pay:
• Deductible.
The deductible is the fixed amount that you will pay before your health benefits
cover your medical services. After this deductible is met, covered services are payable at an
allowable charge
• Copay.
A copay is the amount you pay at the time of service. Typically, copays are for doctor
office visits and prescription medicines
• Coinsurance.
This is the percentage of charges that you are responsible for paying when you
receive a covered service. For example, if your plan states that it will pay 80 percent of allowable
charges for covered services (after your deductible and/or copays have been met), then the
remaining 20 percent is the coinsurance amount you will pay
These amounts are specific to your benefit package.
For all plans, this information is found in the Summary of Benefits and Coverage and when you are
logged in at
. In addition, for HMO plans, the amounts are found on your ID card.