|
Benefit
Description
|
YOU
PAY
|
|
PPO*
|
Non-PPO**
|
| Inpatient
hospitalization
(precertification
required) |
|
Medical/Surgery/Maternity
|
10%
|
30%.
After $100
copayment per admission.
|
| Mental
Health/Substance Abuse |
10% |
50%.
$500 copayment per admission.
All charges
after 50 days.
|
| Outpatient
Hospital |
| Medical/surgery/emergency |
15%
After $250 deductible |
30%.
After $300 deductible. |
| Physician
Care |
| Medical
Care, such as, office visits, lab, 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. |
| 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/Maternity
(Delivery) |
10%.
After $250 deductible. |
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. |
|
|
Network
|
Non-Network
|
| Prescription
Drugs |
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/Maternity |
Nothing
after coinsurance expenses total:
- $4,000 per person
or family for services of PPO/providers/facilities
- $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:
- $3,000 per person
or family for services of network mental health and substance
abuse providers/facilities
- $8,000 per person
for out-of-network mental health and substance abuse inpatient
hospital treatment (to a maximum of 50 days).
|
