UVA Physicians GroupSchedule of Benefits
Base Plan $500/$1,000 Deductible
DEDUCTIBLES AND MAXIMUMS / Tier 1*
HSF/UVA / Tier 2
In-Network / 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
Individual / $3,500 / $4,500
Family / $7,000 / $9,000
Benefit Year Deductible
Individual / $500 / $500 / $500
Family / $1,000 / $1,000 / $1,000
OUTPATIENT SERVICES / Tier 1*
HSF/UVA / Tier 2
In-Network / Tier 3
Out-of-Network
Preventive Care Services (as defined by Southern Health) / $0 / $0 / 40% AC ¹
Physician Home or Office Visit
Primary Care Visit and OBGYN Visit(includes allergy testing and treatment) / $15 / $20 / 40% AC ¹
Specialist Visit / $30 / $35 / 40% AC ¹
Allergy Testing Serum & Injection(If received as part of an office visit the member will only be responsible for the applicable office visit Copayment.) / $30 / $35 / 40% AC ¹
Child Immunizations(If received as part of an office visit the member will also be responsible for the applicable office visit Copayment.) / $0 / $0 / 40% AC ¹
Diagnostic Services (other than specialty diagnostics) / $0 / 20%¹ / 40% AC ¹
Specialty Diagnostic
Including, but not limited to, MRA, MRI, CAT Scan, PET Scan & Sleep Studies / $100 ¹ / $200 then 20% ¹ / 40% AC ¹
Mammogram / $0 / 20%¹ / 40% AC ¹
Outpatient Surgery
Total per visit/study / $100¹ / $200 then 20% ¹ / 40% AC ¹
UrgentCareCenter
When Medically Necessary, as determined by Southern Health / $75 / $75 / $75
MATERNITY SERVICES
/ Tier 1*
HSF/UVA / Tier 2
In-Network / Tier 3
Out-of-Network
Prenatal Care & Postpartum Home or Office Visit
(after the initial office visit for diagnosis of pregnancy) / $0 / 20% ¹ / 40% AC ¹

Maternity Ultrasounds

(other than when performed during physician office visits)

/ $0 / 20% ¹ / 40% AC ¹

InpatientHospital Services

Total per admission to facility / $300¹ / $600 then 20% ¹ / 40% AC ¹
Total per admission to each physician or professional provider / $0¹ / 20% ¹ / 40% AC ¹
EMERGENCY CARE / Tier 1*
HSF/UVA / Tier 2
In-Network / Tier 3
Out-of-Network
Emergency Room Services (true medical emergency)
Total per emergency room visit / $200 / $200 / $200
Ambulance Transportation
Non-emergency transportation must be Preauthorized by Southern Health.
Ground Ambulance / $100 / $100 / $100
Air/Water Transportation / $500 / $500 / $500
BEHAVIORAL HEALTH AND SUBSTANCE ABUSE SERVICES** / Tier 1* And Tier 2
In-Network / Out-of-Network
Inpatient
Total per admission to facility / $300¹ / 40% AC ¹
Total per admission to each physician or professional provider / $0¹ / 40% AC ¹
Outpatient – per visit / $0 / 40% AC ¹
INPATIENT HOSPITAL SERVICES / Tier 1*
HSF/UVA / Tier 2
In-Network / Tier 3
Out-of-Network
Total per admission to facility / $300¹ / $600 then 20% ¹ / 40% AC ¹
Total per admission to each physician or professional provider / $0¹ / 20%¹ / 40% AC ¹
OTHER BENEFITS / Tier 1*
HSF/UVA / Tier 2
In-Network / Tier 3
Out-of-Network

Cardiac Rehabilitation Therapy Maximum 18 outpatient visits percondition

/ 20% ¹ / 20%¹ / 40% AC ¹
Durable Medical Equipment (DME) or Medical Supplies / 20% ¹ / 20% ¹ / 40% AC ¹
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 / $30 / $35 / 40% AC ¹
Assistive Technology Devices / $0 / $0 / 40% AC ¹
Home Health Care Services Maximum 90 visit per Benefit Year / 20%¹ / 20%¹ / 40% AC ¹
Hospice Care / 20% ¹ / 20%¹ / 40% AC ¹
Rehabilitative Services
Inpatient Maximum 30 days per Benefit Year
Total per admission to facility / $300¹ / $600 then 20% ¹ / 40% AC ¹
Total per admission to each physician or professional provider / $0¹ / 20% ¹ / 40% AC ¹
Outpatient – per visit - Occupational, Speech & Physical Therapy Maximum 30 visits per Benefit Year. / 20%¹ / 20% ¹ / 40% AC ¹
Spinal Manipulations Maximum of 10 outpatient visits per Benefit Year / 20%¹ / 20% ¹ / 40% AC ¹
Prosthetic Devices
Prosthetic limbs and components (limbs includes arm, hand, leg, foot or any part of an arm, hand, leg or foot) / 30% ¹ / 30% ¹ / 50% AC ¹
Other Prosthetic Devices
Non-implanted prosthetics other than the prosthetics or components described above. / 50% ¹ / 50% ¹ / 50% AC ¹
Skilled Nursing Facility Maximum 100 inpatient days per Benefit Year / 20% ¹ / 20% ¹ / 40% AC ¹
Transplants
Outpatient services will be the same as the payment responsibility expected at that place of service for any physical illness. / $300¹ / $300¹ / 40% AC ¹
Wisdom Tooth Extractions
Initial Provider Office Visit / $30 / $30 / 40% AC ¹
Surgical Procedure Performed in Provider Office / $50 / $50 / 40% AC ¹
Surgical Procedure Performed in Outpatient Facility / 20% ¹ / 20%¹ / 40% AC ¹

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 Non-Participating 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