(b) A PCP referral is required to see any other provider with the exception of the following services:
(c) O-EPIC IP covered benefits, limits, and applicable co-payments are listed in this subsection. In addition to the benefit-specific limits, there is a maximum lifetime benefit of $1,000,000. Coverage includes:
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(1) Anesthesia / Anesthesiologist Standby. Covered in accordance with OAC 317:30-5-7. Eligible services are covered for covered illness or surgery including services provided by a Certified Registered Nurse Anesthetist (CRNA).
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(2) Blood and Blood Products. Processing, storage, and administration of blood and blood products in inpatient and outpatient settings.
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(3) Chelation Therapy. Covered for heavy metal poisoning only.
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(4) Diagnostic X-ray, including Ultrasound. Covered in accordance with OAC 317:30-5-22(b)(2). PCP referral is required. Standard radiology (X-ray or Ultrasound): $0 co-pay. Specialized scanning and imaging (MRI, MRA, PET, or CAT Scan); $25 co-pay per scan.
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(5) Emergency Room Treatment, services and supplies for treatment in an emergency. Contracted provider services are subject to a $30 co-pay per occurrence. The emergency room co-pay will be waived if the member is admitted to the hospital or death occurs before admission.
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(6) Inpatient Hospital Benefits. Covered in accordance with OAC 317:30-5-41, 317:30-5-47 and 317:30-5-95; $50 co-pay per admission.
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(7) Preventive Office Visit. For services of evaluation and medical management (wellness exam); one visit per year with a $10 co-pay. This visit counts as an office visit.
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(8) Office Visits/Specialist Visits. Covered in accordance with OAC 317:30-5-9, 317:30-5-10, and 317:30-5-11. For services of evaluation and medical management; up to four visits are covered per month; PCP referral required for specialist visits; $10 co-pay per visit.
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(9) Outpatient Hospital/Facility Services.
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(A) Includes hospital surgery services in an approved outpatient facility including outpatient services and diagnostic services. Prior authorization required for certain procedures; $25 co-pay per visit.
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(B) Therapeutic radiology or chemotherapy on an outpatient basis without limitation to the number of treatments per month for persons with proven malignancies or opportunistic infections; $10 co-pay per visit.
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(10) Maternity (Obstetric). Covered in accordance with OAC 317:30-5-22. Nursery care paid separately under eligible child; $50 inpatient hospital co-pay.
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(11) Laboratory/Pathology. Covered in accordance with OAC 317:30-5-20; $0 co-pay.
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(12) Mammogram (Radiological or Digital). Covered in accordance with OAC 317:30-5-901; $0 co-pay.
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(13) Immunizations for Adults. Covered in accordance with OAC 317:30-5-2; $10 co-pay per immunization.
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(14) Assistant Surgeon. Covered in accordance with OAC 317:30-5-8.
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(15) Dialysis, Kidney dialysis, and services and supplies, either at home or in a facility; $0 co-pay.
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(16) Oral Surgery. Services are limited to the removal of tumors or cysts; Inpatient Hospital $50 or Outpatient Hospital/Facility; $25 co-pay applies.
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(17) Mental Health Treatment (Inpatient). Covered in accordance with OAC 317:30-5-95.1; $50 co-pay per admission.
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(18) Mental Health Treatment (Outpatient). Covered in accordance with OAC 317:30-5-241; $10 co-pay per visit.
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(19) Substance Abuse Treatment (Outpatient). Covered in accordance with OAC 317:30-5-241; $10 co-pay per visit.
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(20) Durable Medical Equipment and Supplies. Covered in accordance with OAC 317:30-5, Part 17. A PCP referral and prior authorization is required for certain items. DME/Supplies are covered up to a $15,000 annual maximum; exceptions from the annual DME limit are diabetic supplies, oxygen, home dialysis, and parenteral therapy; $5 co-pay for durable/non-durable supplies and $25 co-pay for durable medical equipment.
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(21) Diabetic Supplies. Covered in accordance with OAC 317:30-5, Part 17; not subject to $15,000 annual DME limit; $5 co-pay per perscription.
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(22) Oxygen. Covered in accordance with OAC 317:30-5, Part 17; not subject to $15,000 annual DME limit; $5 co-pay per month.
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(23) Pharmacy. Covered in accordance with OAC 317:30-5-72.1 and 317:30-5-72. Prenatal vitamins and smoking cessation products do not count against monthly prescription limits; $5/$10 co-pay per prescription.
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(24) Smoking Cessation Products. Products do not count against monthly prescription limits. Covered in accordance with OAC 317:30-5-77.2; $5/$10 co-pay per product.
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(25) Nutrition Services. Covered in accordance with OAC 317:30-5-1076; $10 co-pay per visit.
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(26) External Breast Prosthesis, Bras and Prosthetic Garments. Covered in accordance with OAC 317:30-5, Part 17; $25 co-pay per prosthesis.
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(27) Surgery. Covered in accordance with OAC 317:30-5-8; $50 co-pay per inpatient admission and $25 co-pay per outpatient visit.
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(28) Home Dialysis. Covered in accordance with OAC 317:30-5, Part 17; not subject to $15,000 annual DME limit; $0 co-pay.
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(29) Parenteral Therapy. Covered in accordance with OAC 317:30-5, Part 17; not subject to $15,000 annual DME limit; $25 co-pay per month.
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(30) Family Planning Services and Supplies, including Sterilizations. Covered in accordance with OAC 317:30-3-57; $0 co-pay.
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(31) Home Health Medications, Intravenous (IV) Therapy and Supplies. Covered in accordance with OAC 317:30-5-211(a)(3)(D)(i) and 317:30-5-41(2)(J)(iii).
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(32) Ultraviolet Treatment-Actinotherapy.
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(33) Fundus photography.
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(34) Perinatal dental care for pregnant women. Covered in accordance with OAC 317:30-5-696; $0 co-pay.