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- <?xml version="1.0" encoding="UTF-8"?>
- <benefit-detail>
- <oop-details>
- <productId>08664</productId>
- <planName>Added Advantage POS(SM) 300-100/90/70 Premier</planName>
- <productStartMontNum>1</productStartMontNum>
- <tierTypeCd>S001</tierTypeCd>
- <prodTimefrmDesc>Calendar Year</prodTimefrmDesc>
- <firstDollar>false</firstDollar>
- <firstDollarMaximumIdividual>0.0</firstDollarMaximumIdividual>
- <firstDollarMaximumFamily>0.0</firstDollarMaximumFamily>
- <preferedSavings>false</preferedSavings>
- <deductibleMaxIndividual>300.0</deductibleMaxIndividual>
- <deductibleMaxFamily>600.0</deductibleMaxFamily>
- <oopMaxIndividual>6500.0</oopMaxIndividual>
- <oopMaxFamily>19500.0</oopMaxFamily>
- <oopMaxTwoParty>0.0</oopMaxTwoParty>
- <appliesToAnnualOOPMax>false</appliesToAnnualOOPMax>
- <networks>
- <deductibleIndividual>0</deductibleIndividual>
- <deductibleFamily>0</deductibleFamily>
- <oopIndividual>1500</oopIndividual>
- <oopFamily>4500</oopFamily>
- <oopTwoParty>0</oopTwoParty>
- <networkName>HMO Provider</networkName>
- <networkSortOrderNum>1</networkSortOrderNum>
- <deductibleIndividualCustomRuleId>72</deductibleIndividualCustomRuleId>
- <deductibleFamilyCustomRuleId>73</deductibleFamilyCustomRuleId>
- <oopIndividualCustomRuleId>70</oopIndividualCustomRuleId>
- <oopFamilyCustomRuleId>71</oopFamilyCustomRuleId>
- </networks>
- <networks>
- <deductibleIndividual>0</deductibleIndividual>
- <deductibleFamily>0</deductibleFamily>
- <oopIndividual>3000</oopIndividual>
- <oopFamily>9000</oopFamily>
- <oopTwoParty>0</oopTwoParty>
- <networkName>Preferred Provider</networkName>
- <networkSortOrderNum>2</networkSortOrderNum>
- <deductibleIndividualCustomRuleId>11</deductibleIndividualCustomRuleId>
- <deductibleFamilyCustomRuleId>12</deductibleFamilyCustomRuleId>
- <oopIndividualCustomRuleId>1</oopIndividualCustomRuleId>
- <oopFamilyCustomRuleId>2</oopFamilyCustomRuleId>
- </networks>
- <networks>
- <deductibleIndividual>300</deductibleIndividual>
- <deductibleFamily>600</deductibleFamily>
- <oopIndividual>5000</oopIndividual>
- <oopFamily>15000</oopFamily>
- <oopTwoParty>0</oopTwoParty>
- <networkName>Non-Preferred Provider</networkName>
- <networkSortOrderNum>3</networkSortOrderNum>
- <deductibleIndividualCustomRuleId>14</deductibleIndividualCustomRuleId>
- <deductibleFamilyCustomRuleId>15</deductibleFamilyCustomRuleId>
- <oopIndividualCustomRuleId>4</oopIndividualCustomRuleId>
- <oopFamilyCustomRuleId>5</oopFamilyCustomRuleId>
- </networks>
- </oop-details>
- <year-text>calendar year</year-text>
- <plan-name>Added Advantage POS(SM) 300-100/90/70 Premier</plan-name>
- <fehbp-pland>false</fehbp-pland>
- <service-details>
- <categoryDescription>Physician Services</categoryDescription>
- <subcategoryDescription>In-Office</subcategoryDescription>
- <planName>Added Advantage POS(SM) 300-100/90/70 Premier</planName>
- <tierCode>S001</tierCode>
- <preauthRequired>false</preauthRequired>
- <serviceInfo>
- <ctgryCd>C003</ctgryCd>
- <subctgryCd>S001</subctgryCd>
- <srvcCd>V04</srvcCd>
- <srvcDesc>Surgery</srvcDesc>
- <srvcSortOrderNum>4</srvcSortOrderNum>
- <hlpAvailInd>false</hlpAvailInd>
- <srvcUsedInd>true</srvcUsedInd>
- <srvcCvrdInd>true</srvcCvrdInd>
- <preSrvcInd>true</preSrvcInd>
- <frstDllrApplyInd>false</frstDllrApplyInd>
- <preAuthId>1850</preAuthId>
- <generalCategory>false</generalCategory>
- <providers>
- <ctgryCd>C003</ctgryCd>
- <subctgryCd>S001</subctgryCd>
- <srvcCd>V04</srvcCd>
- <ntwrkCd>HM</ntwrkCd>
- <ntwrkCnsmrName>HMO Provider</ntwrkCnsmrName>
- <ntwrkSortOrderNum>1</ntwrkSortOrderNum>
- <copayment>
- <ctgryCd>C003</ctgryCd>
- <subctgryCd>S001</subctgryCd>
- <srvcCd>V04</srvcCd>
- <ntwrkCd>HM</ntwrkCd>
- <pmtFreqCd>V</pmtFreqCd>
- <pmtTypeCd>D</pmtTypeCd>
- <pmtTypeDesc>$</pmtTypeDesc>
- <pmtAmt>10.0</pmtAmt>
- <ddctblApplyInd>false</ddctblApplyInd>
- <pmtFreqDesc>Visit</pmtFreqDesc>
- <afflNtwrkDsplyInd>false</afflNtwrkDsplyInd>
- <maxType>NULL</maxType>
- <ddctblApplyToOop>false</ddctblApplyToOop>
- <totDdctblIndvlAmt>300.0</totDdctblIndvlAmt>
- <frstDllrApplyInd>false</frstDllrApplyInd>
- <needHelper>true</needHelper>
- <prodNtwkrDesc>HMO Provider</prodNtwkrDesc>
- <oopMaxApplyInd>true</oopMaxApplyInd>
- </copayment>
- </providers>
- <providers>
- <ctgryCd>C003</ctgryCd>
- <subctgryCd>S001</subctgryCd>
- <srvcCd>V04</srvcCd>
- <ntwrkCd>PR</ntwrkCd>
- <ntwrkCnsmrName>Preferred Provider</ntwrkCnsmrName>
- <ntwrkSortOrderNum>2</ntwrkSortOrderNum>
- <copayment>
- <ctgryCd>C003</ctgryCd>
- <subctgryCd>S001</subctgryCd>
- <srvcCd>V04</srvcCd>
- <ntwrkCd>PR</ntwrkCd>
- <pmtFreqCd>V</pmtFreqCd>
- <pmtTypeCd>P</pmtTypeCd>
- <pmtTypeDesc>%A</pmtTypeDesc>
- <pmtAmt>10.0</pmtAmt>
- <ddctblApplyInd>false</ddctblApplyInd>
- <pmtFreqDesc>Visit</pmtFreqDesc>
- <afflNtwrkDsplyInd>false</afflNtwrkDsplyInd>
- <maxType>NULL</maxType>
- <ddctblApplyToOop>false</ddctblApplyToOop>
- <totDdctblIndvlAmt>300.0</totDdctblIndvlAmt>
- <frstDllrApplyInd>false</frstDllrApplyInd>
- <needHelper>true</needHelper>
- <prodNtwkrDesc>Preferred Provider</prodNtwkrDesc>
- <oopMaxApplyInd>true</oopMaxApplyInd>
- </copayment>
- </providers>
- <providers>
- <ctgryCd>C003</ctgryCd>
- <subctgryCd>S001</subctgryCd>
- <srvcCd>V04</srvcCd>
- <ntwrkCd>NP</ntwrkCd>
- <ntwrkCnsmrName>Non-Preferred Provider</ntwrkCnsmrName>
- <ntwrkSortOrderNum>3</ntwrkSortOrderNum>
- <copayment>
- <ctgryCd>C003</ctgryCd>
- <subctgryCd>S001</subctgryCd>
- <srvcCd>V04</srvcCd>
- <ntwrkCd>NP</ntwrkCd>
- <pmtFreqCd>V</pmtFreqCd>
- <pmtTypeCd>P</pmtTypeCd>
- <pmtTypeDesc>%A</pmtTypeDesc>
- <pmtAmt>30.0</pmtAmt>
- <ddctblApplyInd>true</ddctblApplyInd>
- <pmtFreqDesc>Visit</pmtFreqDesc>
- <afflNtwrkDsplyInd>false</afflNtwrkDsplyInd>
- <maxType>NULL</maxType>
- <ddctblApplyToOop>false</ddctblApplyToOop>
- <totDdctblIndvlAmt>300.0</totDdctblIndvlAmt>
- <frstDllrApplyInd>false</frstDllrApplyInd>
- <needHelper>true</needHelper>
- <prodNtwkrDesc>Non-Preferred Provider</prodNtwkrDesc>
- <oopMaxApplyInd>true</oopMaxApplyInd>
- </copayment>
- </providers>
- </serviceInfo>
- <specialDedAndMax>false</specialDedAndMax>
- <dedAmtStart>false</dedAmtStart>
- <benefitMaxAmtStart>false</benefitMaxAmtStart>
- <benefitMaxCntStart>false</benefitMaxCntStart>
- </service-details>
- <serviceInfo>
- <ctgryCd>C003</ctgryCd>
- <subctgryCd>S001</subctgryCd>
- <srvcCd>V04</srvcCd>
- <srvcDesc>Surgery</srvcDesc>
- <srvcSortOrderNum>4</srvcSortOrderNum>
- <hlpAvailInd>false</hlpAvailInd>
- <srvcUsedInd>true</srvcUsedInd>
- <srvcCvrdInd>true</srvcCvrdInd>
- <preSrvcInd>true</preSrvcInd>
- <frstDllrApplyInd>false</frstDllrApplyInd>
- <preAuthId>1850</preAuthId>
- <generalCategory>false</generalCategory>
- <providers>
- <ctgryCd>C003</ctgryCd>
- <subctgryCd>S001</subctgryCd>
- <srvcCd>V04</srvcCd>
- <ntwrkCd>HM</ntwrkCd>
- <ntwrkCnsmrName>HMO Provider</ntwrkCnsmrName>
- <ntwrkSortOrderNum>1</ntwrkSortOrderNum>
- <copayment>
- <ctgryCd>C003</ctgryCd>
- <subctgryCd>S001</subctgryCd>
- <srvcCd>V04</srvcCd>
- <ntwrkCd>HM</ntwrkCd>
- <pmtFreqCd>V</pmtFreqCd>
- <pmtTypeCd>D</pmtTypeCd>
- <pmtTypeDesc>$</pmtTypeDesc>
- <pmtAmt>10.0</pmtAmt>
- <ddctblApplyInd>false</ddctblApplyInd>
- <pmtFreqDesc>Visit</pmtFreqDesc>
- <afflNtwrkDsplyInd>false</afflNtwrkDsplyInd>
- <maxType>NULL</maxType>
- <ddctblApplyToOop>false</ddctblApplyToOop>
- <totDdctblIndvlAmt>300.0</totDdctblIndvlAmt>
- <frstDllrApplyInd>false</frstDllrApplyInd>
- <needHelper>true</needHelper>
- <prodNtwkrDesc>HMO Provider</prodNtwkrDesc>
- <oopMaxApplyInd>true</oopMaxApplyInd>
- </copayment>
- </providers>
- <providers>
- <ctgryCd>C003</ctgryCd>
- <subctgryCd>S001</subctgryCd>
- <srvcCd>V04</srvcCd>
- <ntwrkCd>PR</ntwrkCd>
- <ntwrkCnsmrName>Preferred Provider</ntwrkCnsmrName>
- <ntwrkSortOrderNum>2</ntwrkSortOrderNum>
- <copayment>
- <ctgryCd>C003</ctgryCd>
- <subctgryCd>S001</subctgryCd>
- <srvcCd>V04</srvcCd>
- <ntwrkCd>PR</ntwrkCd>
- <pmtFreqCd>V</pmtFreqCd>
- <pmtTypeCd>P</pmtTypeCd>
- <pmtTypeDesc>%A</pmtTypeDesc>
- <pmtAmt>10.0</pmtAmt>
- <ddctblApplyInd>false</ddctblApplyInd>
- <pmtFreqDesc>Visit</pmtFreqDesc>
- <afflNtwrkDsplyInd>false</afflNtwrkDsplyInd>
- <maxType>NULL</maxType>
- <ddctblApplyToOop>false</ddctblApplyToOop>
- <totDdctblIndvlAmt>300.0</totDdctblIndvlAmt>
- <frstDllrApplyInd>false</frstDllrApplyInd>
- <needHelper>true</needHelper>
- <prodNtwkrDesc>Preferred Provider</prodNtwkrDesc>
- <oopMaxApplyInd>true</oopMaxApplyInd>
- </copayment>
- </providers>
- <providers>
- <ctgryCd>C003</ctgryCd>
- <subctgryCd>S001</subctgryCd>
- <srvcCd>V04</srvcCd>
- <ntwrkCd>NP</ntwrkCd>
- <ntwrkCnsmrName>Non-Preferred Provider</ntwrkCnsmrName>
- <ntwrkSortOrderNum>3</ntwrkSortOrderNum>
- <copayment>
- <ctgryCd>C003</ctgryCd>
- <subctgryCd>S001</subctgryCd>
- <srvcCd>V04</srvcCd>
- <ntwrkCd>NP</ntwrkCd>
- <pmtFreqCd>V</pmtFreqCd>
- <pmtTypeCd>P</pmtTypeCd>
- <pmtTypeDesc>%A</pmtTypeDesc>
- <pmtAmt>30.0</pmtAmt>
- <ddctblApplyInd>true</ddctblApplyInd>
- <pmtFreqDesc>Visit</pmtFreqDesc>
- <afflNtwrkDsplyInd>false</afflNtwrkDsplyInd>
- <maxType>NULL</maxType>
- <ddctblApplyToOop>false</ddctblApplyToOop>
- <totDdctblIndvlAmt>300.0</totDdctblIndvlAmt>
- <frstDllrApplyInd>false</frstDllrApplyInd>
- <needHelper>true</needHelper>
- <prodNtwkrDesc>Non-Preferred Provider</prodNtwkrDesc>
- <oopMaxApplyInd>true</oopMaxApplyInd>
- </copayment>
- </providers>
- </serviceInfo>
- </benefit-detail>
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