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Plan Features
Physician Services
Hospital Services
- Other Medical Services
Prescription Drugs
Mental Health & Substance Abuse
The Industry Health Network
Dental Plan Features
Important Telephone Numbers And Websites
 

  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

  • Under 7 years
85% 70% 80% 70% 60%
Routine Mammograms 85% 70% 80%

70% 60%

  • Under 35
Not covered Not covered Not covered Not covered Not covered
  • Ages 35-39
1 every 5 years 1 every 5 years 1 every 5 years 1 every 5 years 1 every 5 years
  • Ages 40-49
1 every 3 years 1 every 3 years 1 every 3 years 1 every 3 years 1 every 3 years
  • Over 50
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.

 

   
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