 |
|
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:
$1,000, $2,500, $5,000, $7,500
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:
$5,500
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
|
$25 copay
|
$25 copay
|
$25 copay
|
Upfront Outpatient Radiology and Laboratory
First $400 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
|
20% |
50% |
50% |
Other Outpatient Radiology and Laboratory Services
Deductible applies after upfront benefit limits are met.
|
20% |
50% |
50% |
|
Complex Outpatient Imaging (CT Scan, MRI, PET, MRA, SPECT, Bone Density)
|
50% |
50% |
50% |
Hospital Services/Ambulatory Surgical Center
Inpatient and outpatient services and supplies
|
20% |
50% |
50% |
|
Maternity
|
20% |
50% |
50% |
Emergency Room Services
$100 copay per ER visit (waived if directly admitted)
|
20% |
20% |
20% |
Ambulance Services
Air and ground ambulance to the nearest facility
|
20% |
20% |
20% |
Preventive Care (excludes complex imaging)
Not subject to the deductible, no benefit limit
|
20% |
50% |
50% |
Immunizations - Adult and Childhood
Not subject to the deductible, no benefit limit
|
0% |
0% |
0% |
Genetic Testing
$5,000 per lifetime maximum benefit (this limit does not apply to prenatal testing). Deductible applies after upfront benefit limits are met
|
20% |
50% |
50% |
Home Health
130 visits per calendar year
|
20% |
50% |
50% |
Hospice
Respite care limited to 14 days inpatient/outpatient per lifetime
|
20% |
50% |
50% |
Mental Health Treatment
|
20% |
50% |
50% |
Acupuncture
Six visits per calendar year maximum benefit
|
20% |
50% |
50% |
Spinal Manipulations
10 spinal manipulations per calendar year maximum benefit
|
20% |
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)
|
20% |
50% |
50% |
Orthotics
$500 per calendar year maximum benefit (this limit does not apply to diabetic orthotics)
|
20% |
50% |
50% |
Prostheses
$2,500 per calendar year maximum benefit (limit does not apply to surgically implanted and external breast prostheses)
|
20% |
50% |
50% |
Rehabilitation Services
Inpatient: $8,000 per calendar year maximum benefit
Outpatient: $1,500 per calendar year maximum benefit
|
20% |
50% |
50% |
Skilled Nursing Facility
30 inpatient days per calendar year
|
20% |
50% |
50% |
Transplants
$350,000 lifetime maximum benefit, includes donor costs
|
30% |
50% |
50% |
Vision
Routine eye exam and hardware covered to a combined $150 per calendar year maximum; not subject to deductible or coinsurance maximum
|
20% |
20% |
20% |
Breast Reduction, Eye Lid Surgery, Varicose Vein Surgery
$2,500 per lifetime maximum benefit
|
50% |
50% |
50% |
Prescription Medication Coverage
|
$10 copay for generics
$500 deductible, 50% coinsurance for brand formulary only.
$2,500 per calendar year maximum for all drugs (including contraceptives) (No benefit limit for diabetic drugs and supplies).
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