Disclaimers
IN = In-Network, OON = Out-of-Network
* $10,000 annual maximum plan limit for emergency care, urgent care or ambulance outside the USA and its territories.
** Member pays 20% (IN) or 40% (OON) of the cost of genetic testing.
***Allowance is made available by quarter. Allowance carries over quarter to quarter, but does not carry over plan year to plan year. Costs over the allowed amount are the member’s responsibility. This benefit can only be used for covered items through NationsOTC.®
† Limitations, copayments and restrictions may apply. Applicable copays may apply for these benefits. Member must use in-network providers to take advantage of these benefits (excluding Independent Health’s Medicare Passport Advantage PPO plan, Independent Health's Medicare Passport Access PPO plan or Independent Health’s Medicare Passport Prime PPO plan). Must see a Start Hearing network provider to use the hearing aid benefit.
Benefits vary by plan and some plans do not include coverage for these benefits. Benefits, premiums, rewards and/or copayments may change on January 1 of each year. This information is not a complete description of benefits. Call (716) 250-4401 or 1-800-665-1502 (TTY users call 711) for more information.
Out-of-network/non-contracted providers are under no obligation to treat Independent Health members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of-network services.
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