Augustana College
Note: This is a Summary of Benefits; please refer to the Plan Document for a full description of benefits, limitations and maximums.
Medical Expense Benefits
Limitations and Maximums
Annual Deductible:
Annual Out-of-Pocket Maximum: (includes Co-Insurance)
Does not include Deductible, Drug Co-Pays, penalties for failure to pre-certify services, amounts exceeding usual and customary
fees, or ineligible expenses
Medical Expense Benefit Lifetime Maximum:
Covered Expenses
Hospital Services
Includes room & board, special care units, ancillary services, emergency room services Physician Services
Emergency Room
Ambulance Services
Physical, Occupational and Speech Therapy
Durable Medical Equipment
Chiropractic Care/Spinal Manipulation
Laboratory, X-ray and Diagnostic Testing
Home Health Care
Hospice Care
Mental Health/Substance Abuse Treatment
Transplant Services
Preventative Care
(please refer to Plan Document for list of covered services) Maternity and Newborn Care
Skilled Nursing Facility
All other covered expenses
Augustana College
Preferred Provider Networks
This Plan has entered into an agreement with certain Hospitals, Physicians and other health care providers, which are called Participating Providers, or In-Network Providers. Because these Participating Providers have agreed to charge reduced fees to persons covered under the Plan, the Plan can afford to reimburse a higher percentage of their fees.
Therefore, when a Covered Person uses a Participating Provider, that Covered Person will receive a higher benefit percentage from the Plan than when a Non-Participating, or Out-of-Network, Provider is used. It is the Covered Person’s choice as to which Provider to use. The PPO networks for this Plan are: Quad City Community Health Care - or call 888-498-7224
Outside of the Quad City Area: PHCS - or call 866-680-7427
If these services are not pre-certified with QCCH, benefits payable will be reduced by $300 per Covered Individual per incident. The reduction in benefits does not apply to the Annual Deductible or Out-of-Pocket Maximum. - All non-emergency inpatient admissions must be pre-certified prior to the service; emergency inpatient admissions must be
reported within two business days of admission The following services are recommended:
- Durable Medical Equipment purchase over $300 and any rental of durable medical equipment
- All chemotherapy, radiation therapy, home health care and dialysis Outpatient Prescription Drugs
Certain over the Counter Medication to include Claritin, Prilosec, Zantac, and Zyrtec - $10 Co-pay per 30 day supply


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