Administered by Southern Health Services, Inc
UVA Physicians Group Schedule of Benefits
Base Plan $500/$1,000 Deductible
Tier 2
In-Network
Tier 1*
HSF/UVA
DEDUCTIBLES AND MAXIMUMS
Tier 3
Out-of-Network
Benefit Year Out-of-Pocket Maximum
Copayments and Deductible amounts do not apply to the Benefit Year Out-of-Pocket
Maximum
$3,500
Individual
Family
$4,500
$9,000
$7,000
Benefit Year Deductible
Individual
Family
$500
$1,000
$500
$1,000
$500
$1,000
Tier 1*
HSF/UVA
Tier 2
In-Network
Tier 3
Out-of-Network
$0
$0
40% AC ¹
Primary Care Visit and OBGYN Visit (includes allergy testing and treatment)
Specialist Visit
$15
$30
$20
$35
40% AC ¹
40% AC ¹
Allergy Testing Serum & Injection (If received as part of an office visit the
$30
$35
$0
$0
40% AC ¹
40% AC ¹
$0
20% ¹
40% AC ¹
$100 ¹
$200 then 20% ¹
Mammogram
Outpatient Surgery
$0
20% ¹
40% AC ¹
40% AC ¹
Total per visit/study
$100 ¹
$200 then 20% ¹
40% AC ¹
Urgent Care Center
$75
$75
$75
Tier 1*
HSF/UVA
Tier 2
In-Network
Tier 3
Out-of-Network
$0
20% ¹
40% AC ¹
$0
20% ¹
40% AC ¹
$300 ¹
$0 ¹
$600 then 20% ¹
20% ¹
40% AC ¹
40% AC ¹
Tier 1*
HSF/UVA
Tier 2
In-Network
Tier 3
Out-of-Network
$200
$200
$200
$100
$500
$100
$500
$100
$500
OUTPATIENT SERVICES
Preventive Care Services (as defined by Southern Health)
Physician Home or Office Visit
member will only be responsible for the applicable office visit Copayment.)
Child Immunizations (If received as part of an office visit the member will also
be responsible for the applicable office visit Copayment.)
Diagnostic Services (other than specialty diagnostics)
Specialty Diagnostic
Including, but not limited to, MRA, MRI, CAT Scan, PET Scan & Sleep Studies
When Medically Necessary, as determined by Southern Health
MATERNITY SERVICES
Prenatal Care & Postpartum Home or Office Visit
(after the initial office visit for diagnosis of pregnancy)
Maternity Ultrasounds
(other than when performed during physician office visits)
Inpatient Hospital Services
Total per admission to facility
Total per admission to each physician or professional provider
EMERGENCY CARE
Emergency Room Services (true medical emergency)
Total per emergency room visit
Ambulance Transportation
Non-emergency transportation must be Preauthorized by Southern Health.
Ground Ambulance
Air/Water Transportation
SH.HSF.PPO3.7-11
¹ After the Deductible. AC – Allowable Charge
Pending BOI Approval
HSF Base Plan
BEHAVIORAL HEALTH AND SUBSTANCE ABUSE
SERVICES**
Tier 1* And Tier 2
In-Network
Out-of-Network
$300 ¹
$0 ¹
$0
40% AC ¹
40% AC ¹
40% AC ¹
Inpatient
Total per admission to facility
Total per admission to each physician or professional provider
Outpatient – per visit
Tier 1*
HSF/UVA
Tier 2
In-Network
Tier 3
Out-of-Network
$300 ¹
$0 ¹
$600 then 20% ¹
20% ¹
40% AC ¹
40% AC ¹
Tier 1*
HSF/UVA
Tier 2
In-Network
Tier 3
Out-of-Network
20% ¹
20% ¹
20% ¹
20% ¹
40% AC ¹
40% AC ¹
$30
$0
20% ¹
20% ¹
$35
$0
20% ¹
20% ¹
40% AC ¹
40% AC ¹
40% AC ¹
40% AC ¹
$300 ¹
$0 ¹
$600 then 20% ¹
20% ¹
40% AC ¹
40% AC ¹
20% ¹
20% ¹
40% AC ¹
20% ¹
20% ¹
40% AC ¹
Prosthetic limbs and components (limbs includes arm, hand, leg, foot or any
part of an arm, hand, leg or foot)
Other Prosthetic Devices
Non-implanted prosthetics other than the prosthetics or components described
above.
30% ¹
30% ¹
50% AC ¹
50% ¹
50% ¹
50% AC ¹
Skilled Nursing Facility Maximum 100 inpatient days per Benefit Year
Transplants
20% ¹
20% ¹
40% AC ¹
Outpatient services will be the same as the payment responsibility expected at that
place of service for any physical illness.
$300 ¹
$300 ¹
40% AC ¹
$30
$50
20% ¹
$30
$50
20% ¹
40% AC ¹
40% AC ¹
40% AC ¹
INPATIENT HOSPITAL SERVICES
Total per admission to facility
Total per admission to each physician or professional provider
OTHER BENEFITS
Cardiac Rehabilitation Therapy Maximum 18 outpatient visits per condition
Durable Medical Equipment (DME) or Medical Supplies
Early Intervention Services For qualified dependents from birth to age 3.
See eligibility requirements in your Certificate of Insurance.
Home or Outpatient Therapy and Assistive Technology Services
Assistive Technology Devices
Home Health Care Services Maximum 90 visit per Benefit Year
Hospice Care
Rehabilitative Services
Inpatient Maximum 30 days per Benefit Year
Total per admission to facility
Total per admission to each physician or professional provider
Outpatient – per visit - Occupational, Speech & Physical Therapy
Maximum 30 visits per Benefit Year.
Spinal Manipulations Maximum of 10 outpatient visits per Benefit Year
Prosthetic Devices
Wisdom Tooth Extractions
Initial Provider Office Visit
Surgical Procedure Performed in Provider Office
Surgical Procedure Performed in Outpatient Facility
The Benefit Payable is calculated after subtracting from the Allowable Charge any applicable Deductible, Copayment and/or Coinsurance owed by
the Member. Copayment and Coinsurance amounts for maternity related care will be no less favorable than for physical illness generally.
BENEFITS AND BENEFIT YEAR: Benefits listed in this Schedule of Benefits are for Covered Services only. The Benefit Year is the contract
year.
*Tier 1 Providers are HSF/UVA Participating Providers. Tier 2 Providers are all other Participating Providers. Tier 3 Providers are NonParticipating Providers.
**The Behavioral Health and Substance Abuse benefits, as shown on this Schedule of Benefits, are compliant with all provisions of the Mental
Health Parity and Addiction Equity Act (MHPAEA).
¹ After the Deductible
AC – Allowable Charge