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Member Benefits
Subscriber ID Member ID Member Name Benefit
Package		 Funding
Source Code		 Funding
Source Name
9876543210 123456789 PERRIER, NANCY AA04 80XY Client XYZ
 

Member eligibility does not guarantee payment. Benefits are as of today's date.
This is a summary of the member's benefits. For additional information, please submit an inquiry to Customer Service by selecting the inquiry button at the bottom of this page.

Member Detail
Client ID: XYZ
Client Name: Client XYZ
Benefit Package: AA04



SERVICE CATEGORY IN-NETWORK OUT-OF-NETWORK
EAP Benefits
Precert Required Not a Covered Benefit Not a Covered Benefit
Visit Limit Not a Covered Benefit Not a Covered Benefit
Outpatient Psych
Precert Required Yes Yes
Copay Amount $15 - Limit does not apply
Does not Apply
Coinsurance Amount Does not Apply Visits 1 - 30: 50% of Fee Schedule/visit
Annual Deductible Does not Apply Individual -  $500
Combined - Y
Annual Visit Limit Does not Apply Visits 30
Combined - N
Annual Dollar Max Does not Apply For complete details contact Customer Service
Annual Out of Pocket Max Does not Apply Does not Apply
Lifetime Maximum Visit Limit Does not Apply Does not Apply
Lifetime Dollar Maximum Does not Apply For complete details contact Customer Service
Outpatient Substance Abuse
Precert Required Yes Yes
Copay Amount $15 - Limit does not apply
Does not Apply
Coinsurance Amount Does not Apply Visits 1 - 30: 50% of Fee Schedule/visit
Annual Deductible Does not Apply Individual -  $500
Combined - Y
Annual Visit Limit Does not Apply Visits 30
Combined - N
Annual Dollar Max Does not Apply $50,000
Combined - Y
Annual Out of Pocket Max Does not Apply Does not Apply
Lifetime Maximum Visit Limit Does not Apply Does not Apply
Lifetime Dollar Maximum Does not Apply $250,000
Combined - Y
Inpatient Psych
Precert Required Yes Yes
Copay Amount Does not Apply Does not Apply
Coinsurance Amount 0% of Fee Schedule - Limit does not apply
Visits 1 - 30: 50% of Other/visit
Alternative Levels of Care Yes
For complete details contact Customer Service 		Yes
For complete details contact Customer Service
Annual Deductible Does not Apply Individual -  $2,000
Combined - Y
Annual Dollar Max Does not Apply For complete details contact Customer Service
Annual Day Limit Does not Apply Visits 30
Combined - N
Annual Out of Pocket Max Does not Apply Does not Apply
Lifetime Maximum Day Limit Does not Apply Does not Apply
Lifetime Dollar Maximum Does not Apply For complete details contact Customer Service
Inpatient Substance Abuse
Precert Required Yes Yes
Copay Amount Does not Apply Does not Apply
Coinsurance Amount 0% of Fee Schedule - Limit does not apply
Visits 1 - 30: 50% of Other/visit
Alternative Levels of Care Yes
For complete details contact Customer Service 		Yes
For complete details contact Customer Service
Annual Deductible Does not Apply Individual -  $2,000
Combined - Y
Annual Dollar Max Does not Apply $50,000
Combined - Y
Annual Day Limit Does not Apply Visits 30
Combined - N
Annual Out of Pocket Max Does not Apply Does not Apply
Lifetime Maximum Day Limit Does not Apply Does not Apply
Lifetime Dollar Maximum Does not Apply $250,000
Combined - Y

 
 

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