|
BENEFIT DESCRIPTION |
IN-NETWORK |
OUT-OF-NETWORK |
|
Calendar Year Deductible |
$400 (2x Family) |
$400 (2x Family) |
|
Services Rendered in Physician's Office |
|
Office Visits - Primary Care |
$20 Co-pay/100% |
65% |
|
Office Visits - Specialist |
$40 Co-pay/100% |
65% |
|
Surgery/Anest. |
$20 Co-pay/100% |
65% |
|
Child Well Care/Immunizations (to age 6) |
$20 Co-pay/100% |
Not Covered |
|
Adult Well Care
(includes children age 6 and up) |
$20 Co-pay/100%
$500 Annual Limit |
Not Covered |
|
X-Ray & Lab |
$20 Co-pay/100% |
65% |
|
Psych/Mental/Nervous |
85%/25 Visits |
65%/25 visits |
|
Substance |
85%/$100/25 Visits |
65%/$100/25 visits |
|
Physician Services Outside Physician Office |
|
Surgery/Anest. |
85% |
65% |
|
Maternity |
85% |
65% |
|
Newborn Care |
85% |
65% |
|
X-Ray & Lab |
85% |
65% |
|
Hospital Visits |
85% |
65% |
|
Hospital/Facility Services |
|
Semi-Private Room |
85% |
65% |
|
Private Room |
85% SP Rate |
65% SP Rate |
|
Intensive/Coronary Care |
85% |
65% |
|
Nursery Care |
85% |
65% |
|
Drugs & Medications |
85% |
65% |
|
X-Ray & Lab |
85% |
65% |
|
Physical Therapy |
85% |
65% |
|
Emergency Room |
$150 Co-pay/100% |
65% |
|
Surgery/Anest. |
85% |
65% |
|
Inpatient Psych/Substance |
85%/30 Day Limit |
65%/30 Day Limit |
|
Other Services/Supplies |
|
Prescription Drugs - RX PrimeCard/30 day
Tel-Drug Mail Order/90 day supply |
30%Co-Insurance up to $7.00 per RX - Generic
40% Co-Insurance up to $50.00 per RX - Preferred Brand
$50% Co-Insurance up to $75.00 per RX - Non-Preferred Brand
$2000 Combined
|
$200 Deductible
85% |
|
Convalescent Facility |
85% Semi-Private Rate/100 Day Limit |
|
Durable Medical Equipment |
85% |
85% |
|
Prosthetic/Orthopedic Appl. |
85% |
85% |
|
Vision Exams/Lens |
Not Covered |
Not Covered |
|
Ambulance |
85% |
65% |
|
Skilled Private Nursing |
85% |
65% |
|
Home Health Care |
100%/$25,000 Limit |
100%/$25,000 Limit |
|
Hospice |
100%/$25,000 Limit |
100%/$25,000 Limit |
|
Podiatric Care |
$25 Co-pay/50 Visits |
50%/$40/50 Visits |
|
Care of Spinal Conditions |
$25 Co-pay/50 Visits |
50%/$40/50 Visits |
|
Non-Surgical TMJ & Related |
50%/$600 Lifetime |
50%/$600 Lifetime |
|
Maximum Out-Of-Pocket |
$2,000 Individual
$4,000 Family
Excludes Calendar Year Deductible. Excludes Co-pays and 50% coverage areas. |
$2,000 Individual
$4,000 Family |
|
Personal Health Solution
|
|
|
Lifetime Maximums |
|
Substance Abuse |
$10,000 |
|
|
Non-Surgical TMJ |
$600 |
|
|
Home Health Care |
$25,000 |
|
|
Hospice |
$25,000 |
|
|
All Other |
Lifetime |
|
