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*
All hospital inpatient services including; medical/surgical, rehabilitation Chiropractic Services DME Electrophysiological
Hospice Infertility Services; (limited benefit – call customer service) Obesity
Procedures that are cosmetic in nature Prosthetics Self Injectables (approval obtain through injectable program 1-800-562-6223) Skilled Nursing Services Sleep
This is not an inclusive list so please verify with customer service at 1-888-326-2555.
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Value Choice Program 
Value Choice Program 
Prior Authorization Summary