|
REGULAR
PLAN PPO |
LOW
OPTION PLAN
(For COBRA Participants and Extended Coverage Participants Only) |
|
NETWORK
PROVIDER |
NON-NETWORK
PROVIDER |
OUT
OF AREA
(For participants residing outside the PPO service area only) |
NETWORK
PROVIDER |
NON-NETWORK
PROVIDER |
| PHYSICIAN
SERVICES |
| Doctor's
Office Visit 1 |
85% |
70% |
80% |
70% |
60% |
| Periodic
Health Assessment |
Covered
under Wellness Benefits 2 |
Covered
under Wellness Benefits 2 |
Covered
under Wellness Benefits 2 |
Not
covered |
Not
covered |
|
Childhood
Wellness Visits including Immunizations
|
|
|
85% |
70% |
80% |
80% |
60% |
|
|
Covered
under Wellness Benefits 9
|
Covered
under Wellness Benefits |
Covered
under Wellness Benefits |
Not
covered |
Not
covered |
| Adult
Immunization |
Covered
under Wellness Benefits 2 |
Covered
under Wellness Benefits 2 |
Covered
under Wellness Benefits 2 |
Not
covered |
Not
covered |
| Maternity
Care 3 |
85% |
70% |
80% |
70% |
60% |
| Inpatient
Hospital Visit |
85% |
70% |
80% |
70% |
60% |
| Inpatient
Routine Nursery Visits and Room and Board 4 |
85% |
70% |
80% |
70% |
60% |
| Other
Physician Services |
85% |
70% |
80% |
70% |
60% |
| Surgery
5 |
85% |
70% |
80% |
70% |
60% |
1. Includes
lab work and X-rays.
2. See Wellness Benefit, page 8.
3. Includes prenatal care, delivery and postnatal care of a physician-delivered
baby.
4. Inpatient hospital copay applies to the facility fees associated
with the baby;s facility charges.
5. Assistant surgeons may be paid at a reduced benefit level.
|
