Silver Simple PCP Saver CSR 150 - EPO

Cost share applies to both in-person and telemedicine services. Referral care is care provided by a Health Professional or Physician other than your PCP. You may request a second medical opinion from a Participating Specialist Provider who has skills and training substantially similar to those of the Physician making the original treatment recommendation without Prior Approval. If there are no Participating Providers with the skills and training needed to provide a second opinion on the proposed treatment, we may Cover a second medical opinion from a Non-Participating Specialist Provider. Prior Approval from Priority Health is required before the second opinion is obtained. Any tests, procedures, treatments or surgeries recommended by the consulting Provider must be performed by a Participating Provider unless we approve the services in advance.

Covered preventive health care services include: (a) Immunizations (doses, recommended ages, and recommended populations vary), Certain vaccines-children from birth to age 18. Certain vaccines-all adults

Medical Emergency care and Urgent Care services are Covered.

Ambulance includes a motor vehicle or aircraft that is primarily used or designated as available to provide transportation and basic life support, limited advanced life support, or advanced life support. In a Medical Emergency, we will Cover EMT and ambulance service to the nearest medical facility that can provide Medical Emergency care. We will Cover ambulance transfers between facilities that we approve in advance.

(a) Hospital Inpatient Care. Hospital and long term acute inpatient services and supplies including services performed by Physicians and Health Professionals, room and board, general nursing care, drugs administered while you are confined as an inpatient, and related services and supplies.

(a) Hospital Inpatient Care. Hospital and long term acute inpatient services and supplies including services performed by Physicians and Health Professionals, room and board, general nursing care, drugs administered while you are confined as an inpatient, and related services and supplies.

Outpatient services and supplies furnished by a surgery center along with a Covered surgical procedure on the day of the procedure.

Outpatient services and supplies furnished by a surgery center along with a Covered surgical procedure on the day of the procedure.

Therapy and/or Rehabilitative Medicine Services that result in meaningful improvement in your ability to perform functional day-to-day activities that are significant in your life role, physical and occupational therapy, speech therapy for treatment of medical diagnoses, biofeedback for treatment of medical diagnoses. NOTE: Covered physical and occupational therapy services include spinal manipulations by a chiropractor and all manipulations by osteopathic Physicians. Short-term Rehabilitative Medicine Services are Covered if: Treatment is provided for an Illness, Injury or congenital defect for which you have received corrective surgery, and they are provided in an outpatient setting or in the home, and and they result in meaningful improvement in your ability to do important day-to-day activities that are necessary in your life roles within 90 days of starting treatment, and a Participating Physician refers, directs, and monitors the services.

Covered Services(a) Hospital and Provider care. Services and supplies furnished by a Hospital or Provider for prenatal care, including genetic testing, postnatal care, Hospital delivery, and care for the Complications of Pregnancy. The mother and Newborn have the right to an inpatient stay of no less than 48 hours following a normal vaginal delivery or no less than 96 hours following a cesarean section. If the mother and her attending Physician agree, the mother and the Newborn may be discharged from the Hospital sooner. (b) Newborn child care. A Newborn child (including necessary care and treatment of medically diagnosed congenital defects and birth abnormalities) for the first 31 days from birth. Telephone assessment and home visits by a registered nurse shortly after the date of the mother's discharge for evaluation of the mother, Newborn and family. These services are only available if your Provider identifies a medical need. (d) Maternity education programs

Diagnostic and therapeutic radiology services and laboratory tests. All non-emergency laboratory tests, including high-tech radiology examinations, must be performed at a participating laboratory or facility. Radiology services and laboratory tests performed in a Hospital, either while you are an inpatient or an outpatient.

This plan Covers evaluation, consultation and treatment necessary to determine a diagnosis and treatment plan for both acute and chronic mental health conditions. Acute Inpatient Hospitalization.