Samera Health

Covered

Non-Covered

Vision Exam (Children under age 6 only)

In-Network

Out of Network

Plan covers 100%

Covered

Non-Covered

Urgent Care Center & 24 Hours

In-Network

Out of Network

After $50 co-pay per visit, then Plan pays 100%

Covered

Non-Covered

Transplant *

In-Network

Out of Network

Inpatient: Deductible, $140 co-pay per admission, then Plan pays 75% . Outpatient: Deductible, then Plan pays 75%

Covered

Non-Covered

Sterilization - Women

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Sterilization - Men

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Sleep Studies

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Skilled Nursing *

In-Network

Out of Network

Deductible, $140 co-pay, then Plan pays 75%

Covered

Non-Covered

Residential Treatment Facilities (Outpatient Services)

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Residential Treatment Facilities *(Inpatient Services)

In-Network

Out of Network

Deductible, $140 co-pay per admission, then Plan pays 75%

Covered

Non-Covered

PRP Injections

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Outpatient TherapyPhysical, Speech and Occupational

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Outpatient Surgery performed in Physician's office

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Outpatient Surgery *

In-Network

Out of Network

Deductible, $140 co-pay, then Plan pays 75%

Covered

Non-Covered

Mental Health - Outpatient

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Mental Health - Inpatient *

In-Network

Out of Network

Deductible, $140 co-pay per admission, then Plan pays 75%

Covered

Non-Covered

Medical Supplies(Insulin, Diabetic test strips, Insulin pumps, etc.)

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Maternity

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Maternity - (Labs, X-rays, Ultrasounds and related covered services)

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Maternity - Prenatal Office Visits

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Infertility Services (Diagnostic Only)

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Hospital - Outpatient Services(not surgery)

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Hospital - Inpatient Services *

In-Network

Out of Network

Deductible, $140 co-pay per admission, then Plan pays 75%

Covered

Non-Covered

Hospice Care *

In-Network

Out of Network

Inpatient: Deductible, $140 co-pay per admission, then Plan pays 75% Outpatient: Deductible, then Plan pays 75%

Covered

Non-Covered

Home Health Care

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Emergency Room Services

In-Network

Out of Network

Deductible, $200 co-pay per visit, then Plan pays 75%

Covered

Non-Covered

Durable Medical Equipment(includes orthotics & prosthetics)

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Dialysis

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Diagnostic Services - Minor (ultrasounds, ecography,etc)

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Diagnostic Services - Major(MRI, CT, PET, Nuclear Medicine,etc.)

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Diagnostic Services - Basic labs/x-rays

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Diabetic Education

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Dental/Oral Surgeries(Dental Injuries only)

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Colonoscopy (Diagnostic)

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Chiropractic Services

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Chemotherapy/Radiation Therapy

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Chemical Dependency - Outpatient

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Chemical Dependency - Inpatient *

In-Network

Out of Network

Deductible, $140 co-pay per admission, then Plan pays 75%

Covered

Non-Covered

Breast Pumps

In-Network

Out of Network

Plan covers 100%

Covered

Non-Covered

Birth Control Devices, Implants, Injections

In-Network

Out of Network

Plan covers 100%

Covered

Non-Covered

Ambulance (Ground or Air)

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Allergy Treatment - Testing

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Allergy Treatment - Serum

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Allergy Treatment - Injections

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Acupuncture

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Colonoscopy - Preventive

In-Network

Out of Network

Plan covers 100%

Covered

Non-Covered

Preventive Immunizations

In-Network

Out of Network

Plan covers 100%

Covered

Non-Covered

Preventive Care (Children; birth to age 18)

In-Network

Out of Network

Plan covers 100%

Covered

Non-Covered

Preventive Care (Adult)

In-Network

Out of Network

Plan covers 100%

Covered

Non-Covered

Office Services - basic services with exam

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Office Visits - Specialist

In-Network

Out of Network

Deductible, then Plan pays 75%

Covered

Non-Covered

Office Visits - Primary Care

In-Network

Out of Network

Deductible, then Plan pays 75%