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Benefit type

Value Choice Program
Schedule of Benefits for Marin General
Effective January 1, 2006
This Schedule of Benefits is a summary of important terms of your health coverage. The Plan Document must be consulted to determine the exact terms and conditions of coverage. Call Customer Service at 1-888-326-2555 regarding any questions on benefits, providers, coinsurance or copays. This program requires prior authorization for certain procedures, see attached summary. Failure to receive prior authorization will result in nonpayment or a reduction of coverage. Be sure to call customer services at 1-888-326-2555 before these services are rendered. Please note that when you receive hospital services, two separate fees are billed, one by the facility and one by the physician. See appropriate benefit types for copay and coinsurance information. PARTICIPATING PROVIDERS OF
BENEFIT TYPE
ALLERGY TESTING/TREATMENT
AMBULANCE SERVICES
ANNUAL COPAY MAXIMUM
(2 individual maximum per family; does not include copays for
DME, chiropractic benefits)
BLOOD & BLOOD PRODUCTS

CHIROPRACTIC
(20 Visits Maximum per calendar year)
DETOXIFICATION (Inpatient or Outpatient)
 Please call 1-866-374-6060 
This benefit is administered through United Behavioral
Health.
DURABLE MEDICAL EQUIPMENT, CORRECTIVE APPLIANCES
& PROSTHETICS
EMERGENCY/URGENT SERVICES
(Copay is waived if admitted to hospital) FAMILY PLANNING SERVICES
(Including office visits, test, labs, procedures) ™ Depo-Provera medication (limited to one injection
FOOT ORTHOTICS
(Covered for Diabetic foot disease only)
HOME HEALTH CARE

HOSPITAL SERVICES (Inpatient services)

LABORATORY SERVICES
MATERNITY CARE
Value Choice Program
Schedule of Benefits for Marin General
Effective January 1, 2006
This Schedule of Benefits is a summary of important terms of your health coverage. The Plan Document must be consulted to determine the exact terms and conditions of coverage. Call Customer Service at 1-888-326-2555 regarding any questions on benefits, providers, coinsurance or copays. This program requires prior authorization for certain procedures, see attached summary. Failure to receive prior authorization will result in nonpayment or a reduction of coverage. Be sure to call customer services at 1-888-326-2555 before these services are rendered. Please note that when you receive hospital services, two separate fees are billed, one by the facility and one by the physician. See appropriate benefit types for copay and coinsurance information. PARTICIPATING PROVIDERS OF
BENEFIT TYPE
MENTAL HEALTH & CHEMICAL DEPENDENCY COMBINED
 Please call 1-866-374-6060 
™ Inpatient (up to 30 days per calendar year) ™ Outpatient treatment (up to 20 visits per calendar This benefit is administered through United Behavioral
Health.

OUTPATIENT SURGERY
PHYSICIAN SERVICES
™ Office Visits and office consultations PREVENTIVE CARE SERVICES
(For children under 2; including immunizations) ™ Routine Immunizations for children 2 through age 18 ™ Routine Immunizations for adults (Advised by CDC, travel and work immunizations are not covered) ™ Routine radiology and laboratory services in ™ Routine Hearing Screenings (up to age 19)
RADIOLOGY SERVICES

REHABILITATION THERAPY
(Physical, Occupational, Speech)
(Inpatient or Outpatient
SEVERE MENTAL ILLNESS BENEFIT
 Please call 1-866-374-6060 
This benefit is administered through United Behavioral
Health.
SKILLED NURSING CARE
(Up to 100 consecutive calendar days from the first treatment per
disability)
PRESCRIPTION SERVICES
$5 Copay for Generic; $10 Copay for Brand $10 Copay for Generic; $20 Copay for Brand Prior Authorization Summary
MGH Value Choice Program
Effective January 1, 2006*
ƒ All hospital inpatient services including; medical/surgical, rehabilitation ƒ Chiropractic Services ƒ DME ƒ Electrophysiological ƒ Hospice ƒ Infertility Services; (limited benefit – call customer service) ƒ Obesity ƒ Procedures that are cosmetic in nature ƒ Prosthetics ƒ Self Injectables (approval obtain through injectable program 1-800-562-6223) ƒ Skilled Nursing Services ƒ Sleep This is not an inclusive list so please verify with customer service at 1-888-326-2555.

Source: https://fhs.umr.com/oss/export/sites/default/FHS.UMR.com/SharedFiles/MGH_Value_Choice_SOB_101607.pdf

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