 |
|
Lifetime Maximum Benefit |
$2,000,000
|
Calendar Year Deductible
Applies to all covered expenses except where noted
|
Individual deductible options per calendar year for each member:
$2,500, $5,000, $7,500, $10,000
Family deductible is three times the individual amount
|
Calendar Year Coinsurance Maximum
Applies to all covered expenses except where noted. When the coinsurance maximum is reached, this plan provides benefits at 100% of the allowed amount for the remainder of the year |
Individual coinsurance maximum per calendar year for each member:
$7,500
Family coinsurance maximum is three times the individual amount |
|
Covered Services |
Category 1 Preferred |
Category 2 Participating |
Category 3 Non-contracted |
Member Responsibility
Coinsurance applies after deductible is met and until coinsurance maximum is reached. |
Upfront Office Visits (Injury & Illness)
Upfront office visits: first four per calendar year, Not subject to deductible
|
$35 copay
|
$35 copay
|
$35 copay
|
Upfront Outpatient Radiology and Laboratory
First $200 per calendar year (limit does not apply to preventive care or complex outpatient imaging). Not subject to deductible
|
0% |
0% |
0% |
Other Professional Services
Deductible applies after upfront benefit limits are met. Office and inpatient services and supplies
|
30% |
50% |
50% |
Other Outpatient Radiology and Laboratory Services
Deductible applies after upfront benefit limits are met.
|
30% |
50% |
50% |
Complex Outpatient Imaging (CT Scan, MRI, PET, MRA, SPECT, Bone Density)
$1,500 per calendar year maximum benefit
|
50% |
50% |
50% |
Hospital Services/Ambulatory Surgical Center
Inpatient and outpatient services and supplies
|
30% |
50% |
50% |
Emergency Room Services
$150 copay per ER visit (waived if directly admitted)
|
30% |
30% |
30% |
Ambulance Services
Air and ground ambulance to the nearest facility
|
30% |
30% |
30% |
Preventive Care (excludes complex imaging)
Not subject to the deductible, no benefit limit
|
30% |
50% |
50% |
Immunizations - Adult and Childhood
Not subject to the deductible, no benefit limit
|
30% |
50% |
50% |
Genetic Testing
$5,000 per lifetime maximum benefit (this limit does not apply to prenatal testing). Deductible applies after upfront benefit limits are met
|
30% |
50% |
50% |
Home Health
130 visits per calendar year
|
30% |
50% |
50% |
Hospice
Respite care limited to 14 days inpatient/outpatient per lifetime
|
30% |
50% |
50% |
Mental Health Treatment
|
30% |
50% |
50% |
Acupuncture
Six visits per calendar year maximum benefit
|
30% |
50% |
50% |
Spinal Manipulations
10 spinal manipulations per calendar year maximum benefit
|
30% |
50% |
50% |
Durable Medical Equipment
$2,500 per calendar year maximum benefit (limit does not apply to insulin pumps/supplies and lifesaving equipment such as oxygen and ventilators)
|
30% |
50% |
50% |
Prostheses
$2,500 per calendar year maximum benefit (limit does not apply to surgically implanted and external breast prostheses)
|
30% |
50% |
50% |
Rehabilitation Services
Inpatient: $8,000 per calendar year maximum benefit
Outpatient: $1,500 per calendar year maximum benefit
|
30% |
50% |
50% |
Skilled Nursing Facility
30 inpatient days per calendar year
|
30% |
50% |
50% |
Transplants
$350,000 lifetime maximum benefit, includes donor costs
|
30% |
50% |
50% |
Prescription Medication Coverage
|
Rx discount program only
(includes generic & brand formulary drugs).
|
