Microsoft word - ccp 4000 ded - rx 10-25-40 w $100 ded

Non-Network
Deductible1
Coinsurance
Care exclusively from network providers. Lifetime benefits are unlimited. Physician Office Visit (no gatekeeper, no referral)
Includes routine preventive care.
Network Routine Vision Care
Network Injections (if no office visit)
No copay necessary. Covered in full.
Includes al ergy shots.
Network Routine Maternity Physician Services
Includes routine prenatal, delivery, and postnatal care.
No copay necessary for routine maternity services.
Network Preventive Screening and Diagnostic Mammogram (no
age limit) and Preferred Lab Services
No copay necessary. Covered in ful .
Stop Smoking
Limited to three units of covered therapies per year.
Includes Zyban, Chantix and Nicoderm CQ. If a member presents a prescription and enrol s in a covered support program.
Urgent Care
Emergency Care
Outpatient Mental Health/Substance Abuse
$50 per individual or group session. Limited to 20 visits per As coordinated by Behavioral Health Network providers.
year. Non-network benefits are not available.
Covered Specialty Medications and Self Administered Injectible
Medications
COVERAGE AFTER THE ANNUAL DEDUCTIBLE & APPLIES TO OUT-OF-POCKET LIMIT Other Eligible Charges
70% A network provider must coordinate al care.
Hospital, surgical expenses, home health1, skil ed nursing1, x-ray, Mental health and substance abuse services do not apply to rehabilitation services1, outpatient and inpatient services, and COVERAGE WITH NO DEDUCTIBLE & DOES NOT APPLY TO OUT-OF-POCKET LIMIT Durable Medical Equipment (DME)2 and Prosthetic Devices2
70% A network provider must coordinate al care.
Generic Drug Copay
Preferred Brand Drug Copay
Non-Preferred Brand Drug Copay
Lifestyle & Elective Drug Copay
Self-Injectable Drug Copay4
Deductible, per family member
1 If out-of-pocket expenses exceed the per-person or per-family limit during a year, we will pay benefits at 100%. Annual family deductible and out-of -pocket limits are twice the
individual amounts. 2 Benefit limits apply. 3 31- or 90-day supplies may not be available for some prescription medications. Based on the manufacturers’ administration and dosing
guidelines, and the FDA approval of those guidelines, our Pharmacy & Therapeutics Committee establishes quantity limits on selected prescription drugs that apply to retail networkpharmacies and our mail service program. 4 Carolina Care Plan will determine the medications covered within this category and reserves the right to add or remove covered medications Carolina Care Plan®, Inc. provides these summaries to highlight the benefits, exclusions, and limitations.
These summaries should not be relied upon to determine coverage.
 Health services not provided by or under the direction of a participating physician, except urgently needed health services and emergency health services or referral services authorized in advance by Carolina Care Plan  Health services and associated expenses for cosmetic procedures including, but not limited to, pharmacological regimens, nutritional procedures or treatments, plastic surgery, and non-medically necessary reconstructive  Health services and associated expenses for Experimental, Investigational or Unproven Services, treatments,  Health services and associated expenses for infertility services (including in vitro fertilization and gamete intrafallopian transfer [GIFT] procedures), embryo transport, surrogate parenting, donor semen, and non-  Mental health and/or substance abuse services, when such services extend beyond the period necessary for short-term evaluation, diagnosis or crisis intervention; and mental health services for the treatment of mental illnesses, which will not substantially improve beyond the current level of functioning, or for conditions not subject to favorable modification according to generally accepted standards of psychiatric care.
 Custodial care, domiciliary care, respite or rest cures.
 Any loss that results from war or act of war (declared or undeclared), or service in the armed forces of any  Routine foot care, except for the prevention of complications associated with diabetes.
 Treatment or oral appliances for snoring (except for documented obstructed sleep apnea).
 Non-emergency services in a foreign country.
 Pregnancy of dependents (other than Covered Spouse), not including complications of pregnancy.
 Estrogen & testosterone implants.
 Physical therapy provided by a chiropractor.
 Medical/surgical services related to treatment of complications resulting from a non-covered service.
 Services for the evaluation and treatment of TMJ, upper and lower jawbone surgery except as required for direct treatment of acute traumatic injury or cancer.
 Surgical and non-surgical treatment of obesity, including morbid obesity.
Please see Certificate of Coverage for specific details regarding all benefits.

Source: http://teamresources.net/forms/CCP%204000%20Ded%20-%20RX%2010-25-40.pdf