| |
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 |
| OTHER
MEDICAL SERVICES |
|
Alternative
Medicine
- Acupuncture
- Biofeedback
- Chiropractic
1
- Lymphedema
Therapy
- Occupational
Therapy
- Osteopathic
Therapy
- Outpatient
Physical Therapy
|
85%
up to $60/
visit, up to a combined maximum of 50 visits/calendar year; 1 monthly
re-exam to monitor progress (not subject to calendar year maximums)
|
70%
up to $60/
visit, up to a combined maximum of 50 visits/calendar year; 1 monthly
re-exam to monitor progress (not subject to calendar year maximums) |
80%
up to $60/
visit, up to a combined maximum of 50 visits/
calendar year; 1 monthly re-exam to monitor progress (not subject
to calendar year maximums) |
70%
up to $60/
visit, up to a combined maximum of 50 visits/
calendar year; 1 monthly re-exam to monitor progress (not subject
to calendar year maximums) |
60%
up to $60
/visit, up to a combined maximum of 50 visits/
calendar year; 1 monthly re-exam to monitor progress (not subject
to calendar year maximums) |
Ambulance
Air or Sea Ambulance |
85%
$2,500 maximum |
70%
$2,500 maximum |
80%
$2,500 maximum |
70%
$2,500 maximum |
60%
$2,500 maximum |
| Ambulatory
Surgery Center |
85% |
$1,500/
incident maximum |
$1,500/
incident maximum |
70% |
$1,500/
incident maximum |
| Electro-Convulsive
Therapy (ECT) |
85%;
14 visits/
lifetime |
70%;
14 visits/
lifetime |
80%;
14 visits/
lifetime |
70%
; 14 visits/
lifetime |
60%;
14 visits/
lifetime |
| Enhanced
External Counterpulsation Therapy (EECP) |
85%;
35 visits/
calendar year |
70%;
35 visits/
calendar year |
80%;
35 visits/
calendar year |
70%;
35 visits/
calendar year |
60%;
35 visits/
calendar year |
| Hearing
Aids |
50%
2 |
50%
2 |
50%
2 |
50%
2 |
50%
2 |
| Home
Health Care and Home Infusion Therapy |
Mandatory
case management authorization |
Mandatory
case management authorization |
Mandatory
case management authorization |
Mandatory
case management authorization |
Mandatory
case management authorization |
| Hospice
Care |
Mandatory
case management authorization |
Mandatory
case management authorization |
Mandatory
case management authorization |
Mandatory
case management authorization |
Mandatory
case management authorization |
| Infertility
Treatment |
Not
covered |
Not
covered |
Not
covered |
Not
covered |
Not
covered |
| Inversion
Device |
85%;
$500/
lifetime |
70%;
$500/
lifetime |
80%;
$500/
lifetime |
70%;
$500/
lifetime |
60%;
$500/
lifetime |
|
Orthoptic
Training
|
85% |
70% |
80% |
70% |
60% |
| Routine
Mammograms |
85%
|
70% |
80%
|
70%
|
60%
|
|
|
Not
covered |
Not
covered |
Not
covered |
Not
covered |
Not
covered |
|
|
1
every 5 years |
1
every 5 years |
1
every 5 years |
1
every 5 years |
1
every 5 years |
|
|
1
every 3 years |
1
every 3 years |
1
every 3 years |
1
every 3 years |
1
every 3 years |
|
|
1
every year |
1
every year |
1
every year |
1
every year |
1
every year |
| Speech
Therapy (subject to plan restrictions) |
85%
100 visits/
calendar year
Coordinated with speech therapy benefits provided through child's
school. Any sessions covered through school program will reduce visits,
on a one-for-one basis. |
70%
100 visits/
calendar year
Coordinated with speech therapy benefits provided through child's
school. Any sessions covered through school program will reduce visits,
on a one-for-one basis. |
80%
100 visits/
calendar year
Coordinated with speech therapy benefits provided through child's
school. Any sessions covered through school program will reduce visits,
on a one-for-one basis. |
70%
100 visits/
calendar year
Coordinated with speech therapy benefits provided through child's
school. Any sessions covered through school program will reduce visits,
on a one-for-one basis. |
60%
100 visits/
calendar year
Coordinated with speech therapy benefits provided through child's
school. Any sessions covered through school program will reduce visits,
on a one-for-one basis. |
| Treatment
of TMJ Dysfunction |
85%
for X-rays and 6 physiotherapy visits; $150 lifetime maximum for an
appliance or splint, including follow-up visits for adjustments |
70%
for X-rays and 6 physiotherapy visits; $150 lifetime maximum for an
appliance or splint, including follow-up visits for adjustments |
80%
for X-rays and 6 physiotherapy visits; $150 lifetime maximum for an
appliance or splint, including follow-up visits for adjustments |
70%
for X-rays and 6 physiotherapy visits; $150 lifetime maximum for an
appliance or splint, including follow-up visits for adjustments |
60%
for X-rays and 6 physiotherapy visits; $150 lifetime maximum for an
appliance or splint, including follow-up visits for adjustments |
| Vision
Benefits |
85%
for exam, lenses, frames and contacts up to $200/ person/ calendar
year |
85%
for exam, lenses, frames and contacts up to $200/ person/ calendar
year |
85%
for exam, lenses, frames and contacts up to $200/ person/ calendar
year |
Not
covered |
Not
covered |
| Wellness
Benefits (including well child care for children ages 8 and older) |
$500/person
or $1,500/ family/
calendar year for specific wellness or preventive care expenses |
$500/person
or $1,500/ family/
calendar year for specific wellness or preventive care expenses |
$500/person
or $1,500/ family/
calendar year for specific wellness or preventive care expenses |
Not
covered |
Not
covered |
1. Manipulation
of the musculoskeletal system.
2. Covers one device per ear every three years, up to an allowable
charge of $2,000 per device.
31. Services from an Open Access Network or Non-network provider are not subject to the annual deductible.
|
