On This Page: Physician Services, Hospital Services, Vision, Wellness, Mental and Substance Abuse, Prescription Drugs |
|
| LIFETIME MAXIMUM
| None
| |
| |
| |
| CALENDAR YEAR DEDUCTIBLE
| None
| |
| |
| |
|
OUT-OF-POCKET EXPENSE
LIMITATIONS (after deductible) |
$1,500 – individual
$3,500 – for two
$4,500 - family
| |
| |
| |
| PHYSICIAN SERVICES
|
|
| Office Visit (including x-ray & laboratory)
| 100% after $15.00 co-pay | |
| |
| |
| Periodic Health Assessment | 100% after $15.00 co-pay | |
| |
| |
| Well Baby Care | 100% after $15.00 co-pay | |
| |
| |
| Immunizations | 100% | |
| |
| |
| In-Hospital Visits | 100% | |
| |
| |
| Maternity Care (Pre-natal, delivery, post-natal) | 100% after $15.00 co-pay | |
| |
| |
HOME HEALTH CARE
HOME INFUSION THERAPY
& SKILLED HOME NURSING
All treatment must be reviewed for medical necessity through case-management .
|
| When authorized
100%, up to one
visit (equal to 4 hours or less per day)
| |
| |
| |
HOSPICE CARE
All treatment must be reviewed for medical necessity through case-management .
|
| 100% | |
| |
| |
|
HEARING AIDS
|
Not Covered
| |
| |
| |
| HOSPITAL SERVICES
|
|
|
Inpatient (Room and Board, within Plan limits, and Ancillary Services)
| 100% after a $100 per admission co-pay
| |
| |
| |
Outpatient
Outpatient Surgery
| 100% | |
| |
| |
| Outpatient Lab or X-Ray | | |
| |
| |
| Emergency Room | 100% after $50 co-pay that is waived if admitted | |
| |
| |
| ACUPUNCTURE, BIOFEEDBACK, MANIPULATIONS OF THE MUSCULOSKELETAL SYSTEM,
OCCUPATIONAL THERAPY, OSTEOPATHIC MANIPULATIVE TREATMENT AND OUTPATIENT
PHYSICAL THERAPY
| See below 6 | |
| |
| |
|
INFERTILITY
|
Not Covered
| |
| |
| |
CHILD IMMUNIZATION & ALL ASSOCIATED SERVICES
|
|
| Through age 6
| 100%
| |
| |
| |
| Age 7 and above (see Wellness Plan) | 100% | |
| |
| |
|
VISION PLAN
| 85% for exam, lenses and frames, up to a maximum payment of $200 per participant per calendar year. | |
| |
| |
|
WELLNESS PLAN
|
Not Covered
| | |
| |
| | |
| MENTAL AND NERVOUS AND SUBSTANCE ABUSE
|
|
| Mental and/or Nervous Disorders - Inpatient |
100% up to 30 days per facility based care; up to 30 inpatient doctor visits per year (only one visit per day)
| | |
| |
| | |
| Mental and/or Nervous Disorders - Outpatient |
100% after $20 co-pay for a max. of 20 visits per 12-month period; SMI (Severe Mental Illness) $15 co-pay with unlimited number of days
| | |
| |
| | |
| Alcoholism and/or Drug Abuse - Inpatient Only | 100% inpatient detoxification up to 30 days per year for facility based care. 30 inpatient doctor visits per year (only 1 visit a day during each inpatient stay). | | |
| |
| | |
| PRESCRIPTION DRUGS |
|
| Generic/Brand | | |
| |
| | |
| Retail | $10 co-pay
30-day supply
| |
| |
| |
| Mail Order | $10 co-pay
up to a 90-day supply
| | |
| |
| | |
|
|
| 6 | Acupuncture, biofeedback, manipulations of the musculoskeletal system not covered.
Outpatient physical therapy and occupational therapy $15 co-pay per visit for rehabilitative physical therapy and occupational therapy; limited to 60 days per illness or injury. Treatment of TMJ dysfunction 100% after $15 co-pay if medically necessary and authorized by your medical group. The 50 visit maximum cross accumulates between PPO and Non-PPO providers.
| | |
| |
| | |
| Disclaimer | NOTE: This is only a brief summary of your benefits. All benefit descriptions contained herein are governed by the limitations and other information contained in your SPD.
| | |
| |
| | |
