|
Comprehensive Medical Benefit |
| Annual maximum |
$1,250,000 |
Annual maximum effective 1/1/2013 |
$2,000,000 |
| 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) |
| Seasonal Flu Shot |
Plan pays up to $15 per calendar year |
| Screening mammogram |
Plan pays up to $130 per calendar year within age limits (expenses in excess of $130, paid at 80% after Annual Deductible) |
| Laboratory Testing |
Plan pays 100% for tests that are not done by a hospital outpatient department |
|
Covered Services and Supplies with Benefit Limitations |
| Chiropractic therapy |
$1,500 per calendar year |
| Physical therapy, occupational therapy, speech therapy |
25 sessions per illness or injury |
| Cardiac and pulmonary rehabilitation |
30 sessions per event |
| Mental health |
| inpatient |
Maximum of 10 days per calendar year |
| outpatient |
20 visits per calendar year payable at 50% |
| Substance abuse |
3 inpatient detox days and 12 inpatient/outpatient therapy days per acute occurrence |
| Nutritional counseling |
4 counseling sessions per calendar year when certain medical conditions exist |
| Bariatric treatment and management |
6 physician visits per calendar year when history of obesity exists and other conditions are met |
| Bariatric surgery |
when provided through a Fund-approved program |
| Hearing aid |
$500 in any 5-consecutive year period |
| Intentionally destructive act |
Plan pays 50% up to $5,000 per event |
| Pre-existing condition |
Plan pays 50% up to $5,000 per condition (does not apply to patients under age 19) |
| Treatment of varicose veins |
$2,500 per leg, lifetime maximum |
| Voice communication machine |
$7,500, lifetime maximum |
|
Prescription Drug Benefit |
| 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 of |
| Tier Zero—Preferred Drugs |
$0 |
| Tier One—most Generic Drugs |
$7 |
| Tier Two—most Brand Name Drugs and Non-Preferred Generic Drugs |
$15 |
| Tier Three—Non-Preferred Drugs |
$25 |
|
Co-payment for 90-day supply of a maintenance drug is 2 times the 30-day supply co-payment |
