| |
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
- Mammogram 2
- Lifestyle Classes
- Orthoptic Training
- Routine Pap Smear 2
|
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 |
80% |
80% |
80% |
70% |
60% |
| Air or Sea Ambulance |
85%
$5,000 maximum |
70%
$5,000 maximum |
80%
$5,000 maximum |
70%
$5,000 maximum |
60%
$5,000 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 |
| Routine
Mammograms |
Covered under Wellness Benefits |
Covered under Wellness Benefits |
Covered under Wellness Benefits
|
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 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. If Wellness Benefit Maximum is met, routine mammogram and pap smear will be considered under the
medical plan, subject to annual deductible and plan limitations (this doesn't apply to the Low Option plan,
which does not have the Wellness Benefit).
3. 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.
|
