|
|
|
|
|
|
 * |
|
|
| |
| Lifetime
Maximum |
$6,000,000
|
$6,000,000
|
Unlimited
|
| Co-Insurance |
90%
|
70%
|
100%
|
|
| Individual |
$250
|
$250
|
None
|
| Family |
$500
|
$500
|
None
|
|
| Individual |
$2,250
|
$10,250
|
$1,000
|
| Family |
$4,500
|
$20,500
|
$2,000
|
|
| Office Visit |
$15
|
70%
|
$10
|
Preventive
Care
|
$15
|
Not Covered
|
$10
|
Well
Child Care (to age 2)
|
$15
|
Not Covered
|
$10
|
| Chiropractic
Visits (12 visits/year) |
$25
|
70%
|
Not Covered
|
| Laboratory
& X Ray |
90%
|
70%
|
100%
|
Surgery
Center
|
90%
|
70%
|
100%
|
|
Emergency
Room
(Co-pay waived if admitted) |
$50 then 90%
|
$50 then 90%
|
$50
|
| Room
& Board |
90%
|
70%
|
100%
|
| Surgery |
90%
|
70%
|
100%
|
| Laboratory
& X Ray |
90%
|
70%
|
100%
|
| Maternity |
90%
|
70%
|
100%
|
| Routine
Nursery |
90%
|
70%
|
100%
|
|
| Inpatient |
90%
|
70%
|
100%**
|
| Outpatient
(Limited to 20 visits/year) |
$10
|
70%
|
$25 per visit
|
|
| Inpatient |
90%
|
70%
|
100%***
|
| Outpatient
(Limited to 20 visits/year) |
$25
|
Not Covered
|
$25 per visit
|
|
| Generic |
$10
|
Not Covered
|
$10
|
| Formulary |
$15
|
Not Covered
|
$15
|
| Non-Formulary |
$30
|
Not Covered
|
Not Covered
|
| Mail
Order (60 day supply) |
$20/$30/$60
|
Not Covered
|
$20/$30
|
| Please
note that the above benefits are an overview. Exact coverage
and exclusions are available in the summary plan description
booklet. |
|
*
|
When
utilizing network services, please keep in mind that the co-payments
and percentages listed above represent services from a Choice
Provider. When care is obtained from an Affiliated Provider
there will be additional co-pays and out of pocket expense. |
|
**
|
Severe
mental disorders only. |
|
***
|
Acute
phase only. |
Plan Selection
Eligible employees participating in the medical benefits program
must select from the above PPO or HMO plans. Plan selection will
be irrevocable for the duration of the plan year.
Utilization Review
Prior to any hospitalization or surgical procedure it is the members
responsibility to have the services authorized by the utilization
review service. This will ensure payment on services and total out
of pocket expense.
|
