* HMO, or its contracted organization, may use prior authorizations and ongoing reviews to limit the number of outpatient
Mental Health or Substance Abuse visits to the maximum it deems to be Covered Benefits that are Medically Necessary
independent of the maximum number of visits shown in this Schedule of Benefits. This means the Member may not
receive the maximum number of outpatient visits shown in this Schedule of Benefits or the number of outpatient visits the
Member and the treating Provider believe to be appropriate for a single course of treatment or episode.
Outpatient Surgery
Performed at a Hospital Outpatient Facility
Performed at a facility other than a Hospital Outpatient Facility
10% (of the contracted rate) after Deductible
per visit.
$250 after Deductible per visit;
The Copayment percentage applies to all
Covered Benefits incurred during a Member’s
outpatient surgery.
Outpatient Home Health Visits
Limited to 3 intermittent visit(s) per day provided by a
Participating home health care agency; 1 visit equals a period