|
Comprehensive Medical Benefit |
| Lifetime maximum |
$150,000 |
| Annual Deductible |
$250 |
| Non-PPO Hospital Deductible |
$350 |
Non-Compliance Deductible |
$100 |
|
Percentage paid |
| PPO hospital |
Plan pays 85%,
you pay 15% |
| Non-PPO hospital |
Plan pays 65%,
you pay 35% |
| Out-of-area or
emergency hospital |
Plan pays 80%,
you pay 20% |
| Surgery when required
Second Opinion not obtained |
Plan pays 50%,
you pay 50% |
| Most other covered expenses |
Plan pays 80%,
you pay 20% |
| Annual out-of-pocket maximum |
$2,000, including
Annual Deducible |
|
The following benefits are paid at 100% by the Plan and are not subject to the Annual Deductible |
| Preventive care |
Plan pays first $50 per
calendar year (expenses in excess of $50, paid at 80% after Annual Deductible) |
| Screening mammogram |
Plan pays up to $130 per
calendar year within age limits (expenses in excess of $130, paid at 80% after Annual Deductible) |
| Designated Preferred Laboratory Testing |
Plan pays 100% |
|
Other Limits |
| Occupational therapy |
$2,500 per calendar year |
| Physical therapy,
chiropractic therapy, prolo therapy, acupuncture |
Chiropractic therapy
maximum of $1,500 per calendar year; combined maximum of $2,500 for all therapy per calendar year |
| Speech therapy |
$2,500 per calendar year |
| Cardiac rehabilitation |
$1,000 per event |
| Oxygen, outpatient or
portable |
$500 per calendar year
plus the one-time cost of an oxygen concentrator, if applicable |
| Home health care |
$10,000 per calendar
year plus the cost of durable medical equipment, if applicalbe |
| Mental health |
| inpatient |
Maximum of 10 days per
calendar year |
| outpatient |
20 visits per calendar year |
| Substance abuse |
$5,000 lifetime maximum |
| Transplants |
$100,000 per transplant |
| Hearing aid |
$500 in any
5-consecutive year period |
| Intentionally destructive
injury |
Plan pays 50% up to
$5,000 per event |
| Pre-existing condition |
Plan pays 50% up to
$5,000 per condition |
| Hospital charges for
dental surgery |
Plan pays 50% up to
$5,000 per event |
| Treatment of varicose veins |
$2,500 per leg, lifetime maximum |
| Voice communication
machine |
$7,500, lifetime maximum |
|
Prescription Drug Benefit |
| Annual benefit maximum |
$1,500 |
| Percentage paid |
Plan pays 100% after
you pay any co-payment |
| Dispensing limitation |
30-day supply; 90-day
supply for maintenance drug |
|
Co-payment for 30-day supply |
| generic drug |
$7 |
| brand-name drug |
$15 |
| preferred drug |
$0 |
| non-preferred drug |
$25 |
|
Co-payment for 90-day supply of a maintenance drug is 2 times the
30-day supply co-payment |
