OVERVIEW OF BENEFITS
The plan is designed to provide levels of benefits based on the choices you make. Benefits that are payable are subject to the terms and conditions of the plan.
Non-Network Deductible Out-Of-Pocket
(Excluding deductible) Lifetime Maximum (Excludes prescription drugs and
separate $1,000,000 maximum per transplant)
All transplant procedures and specified clinical trials must be pre- Pre-Certification
certified. Failure to pre-certify a transplant procedure or specified clinical trial may result in a reduction or denial in benefits. MEDICAL EXPENSES Non-Network Hospital-Inpatient
80%, after deductible
80%, after deductible Hospital Visits
80%, after deductible Emergency Room
accidental injury)
accidental injury) Urgent Care
80%, after deductible Allergy Testing and Injections
80%, after deductible Ambulance Anesthesia
80%, after deductible
80%, after deductible Cardiac Rehabilitation
80%, after deductible Chemotherapy
80%, after deductible Chiropractic Care
80%, after deductible
Manipulation, Adjustments, Physical Therapy and X-rays
Livingston Educational Services Agency Medical Plan
Non-Network Colonoscopy (Regardless of the diagnosis)
80%, after deductible Consultations
80%, after deductible
80%, after deductible Diabetes Management
80%, after deductible Program - Outpatient Dialysis
80%, after deductible Fertility Testing
80%, after deductible
80%, after deductible Home Health Care Hospice (Respite care limited to 5 days during
a 30 day period) (210 days in a lifetime)
Implants
80%, after deductible Injections Including administration of a covered
80%, after deductible Laboratory Testing
80%, after deductible Mammogram (Limited to1 per calendar year for
80%, after deductible Medical Equipment and Supplies
Including insulin pumps and blood glucose monitors
Mental Disorders and/or Substance Abuse Expenses
80%, after deductible
80%, after deductible Nursing - Private Duty
50%, after deductible Occupational Therapy (Limited to 60 visits in a calendar
80%, after deductible
year combined with speech and physical therapy) Office Visits
80%, after deductible
during the physician’s office visit
80%, after deductible
Livingston Educational Services Agency Medical Plan
Non-Network Orthotics Physical Therapy (Limited to 60 visits in a calendar
80%, after deductible
year combined with occupational and speech therapy)
Pregnancy Related Expenses-
80%, after deductible
80%, after deductible Prescription Drugs
Certain OTC products (including OTC generic equivalents) are covered with a $0 co-pay. (Prescription required) For example, if you are given a
Prescription Drug Over-the-
prescription for Clarinex, you can get only one over-the-counter allergy
Counter-Incentive
medicine reimbursed for the full cost of the over-the-counter medication. Please refer to the section titled “What If I Need A Prescription Medication?” for additional information.
Preventive Care (Limited to $1,000 in a calendar year)
x PSA x Routine Gynecological Exam x Pap Smear x Sigmoidiscopy
Livingston Educational Services Agency Medical Plan
Non-Network Preventive Care (Limited to $1,000 in a calendar year)
NOTE: Immunizations received at the local health department will be covered at 100%
Prosthetic Devices (Specially designed prosthetic bras Radiation Therapy
80%, after deductible Skilled Nursing Facility Specified Clinical Trials
80%, after deductible Speech Therapy (Limited to 60 visits in a calendar
80%, after deductible
year combined with occupational and physical therapy) Transplants
Human Organs (Cornea, Kidney, Skin)
80%, after deductible
$10,000 maximum for transportation, meals and lodging for patient and 1 companion (2 if the patient is a minor)
Livingston Educational Services Agency Medical Plan
Non-Network Transplants
80% after deductible Transplants
Lung (Limited to a separate $1,000,000 maximum per transplant) $10,000 maximum for transportation, meals and lodging for patient and 1 companion (2 if the patient is a minor)
Weight Management for Morbid
80%, after deductible All Other Covered Expenses
80%, after deductible
NOTE: This is only a brief overview of benefits. Please refer to the sections of the plan for
complete information on the eligibility provisions, limitations and for all other terms of the plan. Any maximums listed are applicable to all plan levels.
Livingston Educational Services Agency Medical Plan
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"The Problem with Hoodia" “Hello, I'm Roger. So, what takes you to Africa? Work or pleasure?” Angela Bingham turned to her seatmate and tried to muster a genuine smile. Although she was proud of her work, Angela thought it odd that a stranger would try to start a conversation by asking such a personal question. Nevertheless, she was stuck sitting next to this man for the remainder