| NOTE: items in RED here are new changes in the policy as of August 1st, 2011 |
Deductible and Out-of-Pocket Maximum | PPO Provider | Non-PPO Provider | ||
|---|---|---|---|---|
| Calendar Year Deductible | $200 per person $400 per family | $200 per person $400 per family | ||
| Out-of-Pocket Maximum*(Including Deductible) | $1,200 per person $2,000 per family | |||
| *When the Out-of-Pocket Maximum is reached, Plan payments made at 80% will increase to 100% of UCR. The following expenses do not apply toward your Out-of-Pocket Maximum: your Copays; any benefit reduction for not following Hospital Pre-admission Certification requirements; and non-covered expenses, including charges | ||||
Provisions and Limitations | ||||
Hospital Utilization Review ServicesHospital Pre-admission Certification; Concurrent Review; Discharge Planning; Maternity Care Review; and Individual Case Management Required | ||||
Hospital Pre-Admission CertificationNotification recommended within 48 hours for emergency. Notification recommended 7 days prior to an elective surgery. | ||||
Covered Medical Expenses | ||||
Service | PPO Provider | Non-PPO Provider | ||
Hospital Expenses | ||||
| Inpatient Room & Board & Ancillary | 80% after the deductible | 80% of UCR after the deductible | ||
| Outpatient Facility (medical) | 80% after the deductible | 80% of UCR after the deductible | ||
| Outpatient Facility (surgical) | 80% after the deductible | 80% of UCR after the deductible | ||
| Outpatient Facility (DXL) | 100% | 80% of UCR after the deductible | ||
Physicians’ and Surgical Expenses | ||||
| Inpatient Surgery** | 80% after the deductible | 80% of UCR after the deductible | ||
| Inpatient Visits | 100% after $10 copay | 80% of UCR after the deductible | ||
| Outpatient Surgery (Hosp/ASC)** | 80% after the deductible | 80% of UCR after the deductible | ||
| Outpatient Surgery (office)** | 80% after the deductible | 80% of UCR after the deductible | ||
| Second and Third Surgical Opinions | 100% after the deductible | 100% of UCR after the deductible | ||
| Specialist Office Visits (includes diagnostic services) | 100% after $10 copay | 80% of UCR after the deductible | ||
| Office Visits (includes diagnostic services); | 100% after $10 copay | 80% of UCR after the deductible | ||
|
**Anesthesia is paid at the same level as Surgery. |
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Covered Medical Expenses | ||
|---|---|---|
Service | PPO Provider | Non-PPO Provider |
Mental Health Treatment Expenses | ||
| Inpatient | 80% after the deductible | 80% of UCR after the deductible |
| Outpatient Visits | 100% after $10 copay | 80% of UCR after the deductible |
| Partial Stay | 80% after the deductible | 80% of UCR after the deductible |
Substance Abuse Treatment Expenses | ||
| Inpatient Rehab | 80% after the deductible | 80% of UCR after the deductible |
| Inpatient Detox | 80% after the deductible | 80% of UCR after the deductible |
| Outpatient Rehab Visits | 100% after $10 copay | 80% of UCR after the deductible |
| Outpatient Detox Visits | 100% after $10 copay | 80% of UCR after the deductible |
| Partial Stay | 80% after the deductible | 80% of UCR after the deductible |
Emergency Care | ||
| Emergency Room (Hospital) | 80% after the deductible | 80% of UCR after the deductible |
| Emergency Room Physician | 80% after the deductible | 80% of UCR after the deductible |
| Emergency Room Diagnostic | 80% after the deductible | 80% of UCR after the deductible |
| Non-Emergent use of ER | 80% after the deductible | 80% of UCR after the deductible |
| Out of Area ER | No Network Available | 80% of UCR after the deductible |
| ER Accident or Sudden Illness (Physician) | 100% after $10 copay | 100% of UCR after $10 copay |
| Urgent Care Facility | 80% after the deductible | 80% of UCR after the deductible |
Preventive Care Expenses* | ||
| Immunization (adult – age 18 and over) | 100% | 80% of UCR after the deductible |
| Immunization (child – birth to age 18) | 100% | 80% of UCR after the deductible |
| Routine Annual Physical Exam (over age 18) | 100% after $10 copay | 80% of UCR after the deductible |
| Routine Diagnostic Procedures | 100% | 80% of UCR after the deductible |
| Routine Gynecological Procedure | 100% | 80% of UCR after the deductible |
| Routine Mammography | 100% | 80% of UCR after the deductible |
| Well-Child Care (birth to age 18) | 100% | 80% of UCR after the deductible |
Therapies | ||
| Cardiac Rehab | 80% after the deductible | 80% of UCR after the deductible |
| Chemotherapy/Radiation Therapy | 80% after the deductible | 80% of UCR after the deductible |
| Dialysis | 80% after the deductible | 80% of UCR after the deductible |
| Occupational Therapy | 80% after the deductible | 80% of UCR after the deductible |
| Physical Therapy | 80% after the deductible | 80% of UCR after the deductible |
| Respiratory Therapy | 80% after the deductible | 80% of UCR after the deductible |
| Speech Therapy (Restorative purposes only) | 80% after the deductible | 80% of UCR after the deductible |
* Charges for Preventive Care Expenses are covered pursuant to PPACA/Health
Care Reform guidelines. |
||
Covered Medical Expenses | ||
|---|---|---|
Service | PPO Provider | Non-PPO Provider |
Other Covered Expenses | ||
| Acupuncture | 80% after the deductible | 80% of UCR after the deductible |
| Ambulance Service | 80% after the deductible | 80% of UCR after the deductible |
| Allergy Injections | 80% after the deductible | 80% of UCR after the deductible |
| Allergy Testing | 80% after the deductible | 80% of UCR after the deductible |
| Allergy Serum | 80% after the deductible | 80% of UCR after the deductible |
| Chiropractic Treatment | 80% after the deductible | 80% of UCR after the deductible |
| Diagnostic, X-ray and Lab | 100% | 80% of UCR after the deductible |
| Durable Medical Equipment | 80% after the deductible | 80% of UCR after the deductible |
| Home Health Care | See Non-PPO Benefits | 80% of UCR after the deductible |
| Hospice Care | See Non-PPO Benefits | 80% of UCR after the deductible |
| Orthotics | 80% after the deductible | 80% of UCR after the deductible |
| Pre-Admission Testing | 80% after the deductible | 80% of UCR after the deductible |
| Private Duty Nursing | See Non-PPO Benefits | 80% of UCR after the deductible |
| Prosthetics | 80% after the deductible | 80% of UCR after the deductible |
| Skilled Nursing Facility | See Non-PPO Benefits | 80% of UCR after the deductible |
| Temporomandibular Joint (TMJ) and Myofascial Pain Dysfunction (MPD) Treatment | 80% after the deductible | 80% of UCR after the deductible |
| All Other Eligible Medical Expenses | 80% after the deductible | 80% of UCR after the deductible |
Infertility | ||
| Infertility Diagnostic | 80% after the deductible | 80% of UCR after the deductible |
| Infertility/AI-IVF | Not Covered | Not Covered |
Prescription Drugs | ||
Prescription | Co-Insurance/Co-Pay | |
| Retail Pharmacy Generic (Up to 30 days) | $15 copay per prescription | |
| Retail Pharmacy Brand Name Formulary (Up to 30 days) | $35 copay per prescription | |
| Retail Pharmacy Brand Name Non-Formulary (Up to 30 days) | $50 copay per prescription | |
| Mail Order Generic (Up to 90 days) | $30 copay per prescription | |
| Mail Order Brand Name Formulary (Up to 90 days) | $70 copay per prescription | |
| Mail Order Brand Name Non-Formulary (Up to 90 days) | $100 copay per prescription | |
Service | Maximum Benefit per Person |
Medical | |
| Lifetime Maximum for all Eligible Medical Expenses | Unlimited |
| Routine Gynecological Exam | 1 visit per calendar year |
| Routine Physical Exam | 1 visit per calendar year |
| Well-Child Care | Birth to age 18 |
| Home Health Care | 100 visits per calendar year |
| Skilled Nursing Facility | 180 days per calendar year |
| Hospice Care Lifetime Maximum | 180 days per calendar year |
| Acupuncture Care | 30 visits per calendar year |
| Chiropractic Care | 30 visits per calendar year |
| Infertility Testing | $1,500 per calendar year |
| Organ Transplant Travel Benefit | $250 per day up to $8,000 per transplant for lodgings and meals |
| Temporomandibular Joint (TMJ) and Myofascial Pain Dysfunction (MPD) Treatment | $1,000 per calendar year |
| Pre Existing Limitations Time Period and $$ Limits | No treatment three months prior to enrollment date or covered under the plan for 12 months. Does not apply to enrollees under the age of 19. |
Prescription Drugs | |
| Maximum Supply Retail Pharmacy Prescriptions | 30 days |
| Maximum Supply Mail Order Pharmacy Prescriptions | 90 days |
Employees Short-Term Disability | |
| Weekly Benefit Amount | 50% of Regular and Basic Weekly Earnings |
| Maximum Benefit Period | $500 |
| All benefits described in the Schedule are subject to the exclusions and limitations described more fully herein including, but not limited to, the Plan Administrator’s determination that: care and treatment is Medically Necessary; that charges are Usual, Customary and Reasonable; that services, supplies and care are not Experimental and/or Investigational. |
Dental Deductible(Classes B and C combined) $50 Per Person $100 Per Family | |
|---|---|
Service | Benefit Provided |
| Class A – Diagnostic and Preventive | 100% of UCR |
| Class B – Restorative | 80% of UCR after the deductible |
| Class C – Major | 50% of UCR after the deductible |
| Class D – Orthodontia-until age 19 | 50% of UCR |
Dental Schedule of Plan Maximums | |
| Service | Maximum Benefit Per Person |
| Class A – Diagnostic and Preventive | $2,000 per calendar year |
| Class B – Restorative | |
| Class C – Major | |
| Lifetime Maximum for Orthodontia Treatment | $1,000 per lifetime |
| • Initial or periodic oral exams, Prophylaxis
and fluoride treatments are limited to two per calendar year. • Fluoride treatments limited to covered persons under the age of 18. • Space maintainers limited to covered persons under the age of 16 and limited to the initial appliance only with adjustments in the first six months of installation. |
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