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A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. The Summary of Benefits & Coverage can be found at.Insurance companies reserve the right to change the terms of a policy upon proper notification. The insurance company always determines your actual premium. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date.
The quotes or rates shown above are estimates only. Please check below for information regarding the plans and carriers you selected. These amounts are subject to change.Įach insurance carrier may have unique Notices, Disclaimers, and Fees. The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network. Only the terms and conditions of coverage benefits listed in the policy are binding. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) for a detailed description of coverage benefits, limitations, and exclusions. The information shown here is a summary of benefits for informational purposes only. Ascension has invested 54M on a renovation and expansion for the Warren Campus that was completed in May 2019. Out-of-Network Annual Out-of-Pocket LimitĮlectronic Signature for Application Available John Detroit Riverview in 2007, the program has since resided at Ascension Macomb-Oakland Hospital which has been an integral part of Southeast Michigan since March of 1966. No Charge after deductible, limited to 30 Visit(s) per Year No Charge after deductible, limited to 45 Days per Year Inpatient Hospital Services: No Charge after deductible Inpatient Physician and Surgical Services: No Charge after deductible No Charge after deductible, limited to 90 Visit(s) per Year Outpatient Rehabilitation Services (PT, OT, ST) Outpatient Lab: No Charge after deductible X-rays: No Charge after deductible Outpatient Surgery Physician/Surgical Services: No Charge after deductible Outpatient Facility Fee: No Charge after deductible Generic Drugs: $5 Copay Preferred Brand Drugs: No Charge after deductible Non-Preferred Brand Drugs: No Charge after deductible Specialty Drugs: No Charge after deductible
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