|
Benefit
Description |
YOU
PAY |
|
PPO |
Non-PPO |
| Inpatient
hospitalization
(precertification
required) |
|
Medical/Surgery
|
*10% |
30%
After $100
copayment per admission |
| Maternity |
Nothing |
30%
After $100 copayment per admission |
| Mental
Health/Substance Abuse |
*10% |
50%
$500 copayment per admission
All charges
after 50 days |
| *Your coinsurance expenses for inpatient services billed by a network hospital facility will never exceed $2000. |
| Outpatient
Hospital |
| Medical/surgery/emergency |
15%
After $250 deductible |
30%
After $300 deductible |
| Physician
Care |
| Medical
Care, such as: office visits, x-ray and diagnostic services |
$20
copayment per office visit
15% for most other services
After $250 deductible |
30%
for most other services
After $300 deductible |
| Laboratory Services |
Nothing using Lab Savings Program |
30%
After $300 deductible |
| Annual routine physical exam (age 22 or older) |
$20 copayment |
30%
After $300 deductible |
| Well
child care (up to age 3) and immunizations (up to age 22) |
Nothing |
The difference,
if any, between our payment and the billed charges |
| Surgery |
10%
After $250 deductible |
30%
After $300 deductible |
| Complete maternity care (obstetrical) |
Nothing |
30%
After $300 deductible |
| Accidental
Injury (Nonsurgical care) |
Within 72 hours:
Nothing
After 72 hours:
15%
After $250 deductible |
Within
72 hours: The difference, if any, between our payment and the
billed charges
After 72 hours: 30%
After $300 deductible |
| Mental
Health and Substance Abuse Care |
$20
copayment per office visit
15% for other services
After $250 deductible |
50%
After $300 deductible
All charges after 30 visits |
|
Prescription Drugs |
Network |
Non-Network |
Retail
Pharmacy
(1) You must receive prior authorization for biotech/specialty
drugs or benefits will be reduced.
(2) This is a mandatory generic program with a 30-day dispensing
limit |
1st and 2nd fill:
25% of cost
3rd (or more) fill:
Full cost at time of purchase
You will need to file a claim to receive a 50% reimbursement
of the Plan Allowance after a $25 deductible is met |
Full
cost at time of purchase
You will need to file a claim to receive a 50% reimbursement
of the Plan Allowance after a $25 deductible is met |
| Mail
Order Program |
60-day
supply: $8
generic/$24 name brand
90-day supply: $12
generic/$35 name brand |
| Catastrophic
Limits |
| Medical/Surgery |
Nothing
after coinsurance expenses total:
- $4,000 per person
or family for services of PPO/providers/facilities. Your coinsurance expenses for inpatient services billed by PPO hospital facilities will never exceed $2000.
- $6,000 per person
or family for services of PPO and non-PPO providers/facilities
combined.
|
| Mental
Health and Substance Abuse |
Nothing after coinsurance
expenses total:
- $4,000 per person
or family for services of network mental health and substance
abuse providers/facilities. Your coinsurance expenses for inpatient services billed by network hospitals or other facilities will never exceed $2000.
- $8,000 per person
for out-of-network mental health and substance abuse inpatient
hospital treatment (to a maximum of 50 days).
|
