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  Home > Health Plan > B5 - Summary of Benefits

SUMMARY OF BENEFITS

The following chart highlights key features of your Plan.

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

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