A High Deductible Health Plan (HDHP) has a higher calendar year deductible than a typical health plan. Most services are covered only after you meet your Deductible. Some preventive care benefits may be paid before the Deductible is satisfied. When you are covered under a HDHP, you may qualify for tax savings by contributing to a Health Savings Account (HSA). An HSA is a custodial account used to pay for qualified medical expenses. HSAs are regulated by the Internal Revenue Service. An HSA is not part of your employer-sponsored and maintained benefits program. To receive the maximum benefit from the Plan, make sure to use a Provider that is a member of the BlueCross BlueShield P Provider Network.
SERVICES RECEIVED AT THE PRACTITIONER’S OFFICE
COVERED SERVICES
PLAN’S PAYMENT FOR COVERED SERVICES
Received from NHC or an NHC Affiliate
Received from Network Providers1
Received from Out-of- Network Providers2 Office Exams and Consultations
Diagnosis and treatment of injury or illness 80% after Deductible 60% after Deductible
Maternity office visits 80% after Deductible 60% after Deductible
Preventive – Children under age 6 100% No Copayment 60% after Deductible
Well Woman Exam & Wellcare Exam – Ages 6 and up3 100% No Copayment 60% after Deductible
Injections and Immunizations
Allergy injections and allergy serum 80% after Deductible 60% after Deductible
Immunizations, under age 6 100% No Copayment 60% after Deductible
Immunizations, age 6 and above 100% No Copayment 60% after Deductible
All other injections 80% after Deductible 60% after Deductible
Diagnostic Services and Preventive Screenings (e.g. x-ray and labwork)
Allergy Testing 80% after Deductible 60% after Deductible
Non-Routine Advanced Radiological Imaging Services4 80% after Deductible 60% after Deductible All Other Diagnostic Services for illness or injury 80% after Deductible 60% after Deductible Maternity care diagnostic services 80% after Deductible 60% after Deductible
Preventive Screenings, under age 6 100% No Copayment 60% after Deductible
Preventive Mammogram, Bone Density, Cervical Cancer Screening,
Prostate Screening and Colorectal Cancer Screening5 100% No Copayment 60% after Deductible Other Wellcare Screenings, age 6 and above 100% No Copayment 60% after Deductible Preventive/Well Care Services
Includes preventive health exam, screenings and counseling services. Alcohol misuse and tobacco use counseling limited to 8 visits annually; must be provided in the primary care setting; Dietary counseling for adults with hyperlipidemia, hypertension, Type 2 diabetes, coronary artery disease and congestive heart failure limited to 6 visits annually.
100% No Copayment 60% after Deductible Lactation counseling by a trained provider during pregnancy or in the
post-partum period. Limited to one visit per pregnancy. 100% No Copayment 60% after Deductible Manual Breast Pump, limited to one per pregnancy 100% No Copayment 60% after Deductible FDA-approved contraceptive methods, sterilization procedures and
counseling for women with reproductive capacity. 100% No Copayment 60% after Deductible
Other office procedures, services or supplies
Office Surgery, including anesthesia6, 7 80% after Deductible 60% after Deductible Therapy Services: Physical, speech, and occupational, therapy 100% after Ded 80% after Deductible 60% after Deductible Chiropractic and manipulative therapy 80% after Deductible 60% after Deductible
Cardiac and pulmonary rehab 80% after Deductible 60% after Deductible
DME 80% after Deductible 60% after Deductible
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SERVICES RECEIVED AT A FACILITY
COVERED SERVICES
PLAN’S PAYMENT FOR COVERED SERVICES
Received from NHC or an NHC Affiliate
Received from Network Providers1
Received from Out-of- Network Providers2 Inpatient Hospital Stays, including maternity stays8
Facility charges 80% after Deductible 60% after Deductible
Practitioner charges 80% after Deductible 60% after Deductible
Skilled Nursing or Rehab Facility stays(limited to 365 days per incident) 8
Facility charges 100% after
Deductible 80% after Deductible 60% after Deductible
Practitioner charges 80% after Deductible 60% after Deductible
Hospital Emergency Care Services
Emergency Room Charges 80% after Deductible 80% after Deductible
Non-Acute/Non-Emergency Use
of Emergency Room 80% after Deductible 60% after Deductible
Non-Routine Advanced Radiological Imaging Services4 80% after Deductible 60% after Deductible
All Other Hospital Charges 80% after Deductible 60% after Deductible
Practitioner Charges 80% after Deductible 60% after Deductible
Outpatient Facility Services / Outpatient Surgery6,7
Facility charges 80% after Deductible 60% after Deductible
Practitioner charges 80% after Deductible 60% after Deductible
Outpatient Diagnostic Services and Outpatient Preventive Screenings
Non-Routine Advanced Radiological Imaging Services4 80% after Deductible 60% after Deductible All other Diagnostic Services for illness/injury 80% after Deductible 60% after Deductible Maternity care diagnostic services 80% after Deductible 60% after Deductible
Preventive Screenings, under age 6 100% No Copayment 60% after Deductible
Preventive Mammogram, Bone Density, Cervical Cancer, Prostate
Screening and Colorectal Cancer Screening5 100% No Copayment 60% after Deductible Other Wellcare Screenings, age 6 and above 100% No Copayment 60% after Deductible Preventive/Well Care Services
Includes preventive health exam, screenings and counseling services. Alcohol misuse and tobacco use counseling limited to 8 visits annually; must be provided in the primary care setting. Dietary counseling for adults with hyperlipidemia, hypertension, Type 2 diabetes, coronary artery disease and congestive heart failure limited to 6 visits annually.
100% No Copayment 60% after Deductible
Lactation counseling by a trained provider during pregnancy or in the
post-partum period. Limited to one visit per pregnancy. 100% No Copayment 60% after Deductible Manual Breast Pump, limited to one per pregnancy 100% No Copayment 60% after Deductible FDA-approved contraceptive methods, sterilization procedures and
counseling for women with reproductive capacity. 100% No Copayment 60% after Deductible
Other Outpatient Procedures, Services or Supplies
Therapy Services: Physical, speech, and occupational therapy 100% after
Deductible 80% after Deductible 60% after Deductible Chiropractic and Manipulative Therapy 80% after Deductible 60% after Deductible
Cardiac and Pulmonary Rehab 80% after Deductible 60% after Deductible
Durable Medical Equipment (DME) 80% after Deductible 60% after Deductible
Orthotics and Prosthetics 80% after Deductible 60% after Deductible
Supplies 80% after Deductible 60% after Deductible
All Other services received at an Outpatient Facility, including
OTHER SERVICES
COVERED SERVICES
PLAN’S PAYMENT FOR COVERED SERVICES
Received from NHC or an NHC Affiliate
Received from Network Providers1
Received from Out-of- Network Providers2
Ambulance 80% after Deductible 80% after Deductible
Home Health Care Services8 100% after
Deductible 80% after Deductible 60% after Deductible
Home Infusion Therapy8 100% after
Deductible 80% after Deductible 60% after Deductible
Hospice Care8 100% after
Deductible 80% after Deductible 60% after Deductible
Durable Medical Equipment (DME) 80% after Deductible 60% after Deductible
Orthotics and Prosthetics 80% after Deductible 60% after Deductible
Supplies 80% after Deductible 60% after Deductible
BEHAVIORAL HEALTH SERVICES
COVERED SERVICES
PLAN’S PAYMENT FOR COVERED SERVICES
Received from Network Providers1
Received from Out-of- Network Providers2
Inpatient8 80% after Deductible 60% after Deductible
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