|
Lifetime Maximum Benefit |
No Overall Lifetime Maximum
|
|
Annual 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 and Immunizations
Not subject to the deductible
|
0% |
0% |
Standard Category 3 Benefits Apply |
Genetic Testing
|
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
|
20% |
50% |
50% |
Orthotics
|
20% |
50% |
50% |
Prostheses
|
20% |
50% |
50% |
Rehabilitation Services
Inpatient: 10 days per calendar year maximum benefit
Outpatient: 25 visits per calendar year maximum benefit
|
20% |
50% |
50% |
Skilled Nursing Facility
30 inpatient days per calendar year
|
20% |
50% |
50% |
Transplants
|
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
|
50% |
50% |
50% |
Prescription Medication Coverage
|
$10 copay for generics
$500 deductible, 50% coinsurance for brand formulary only.
We cover certain preventive medications according to United States Preventive Services Task Force (USPSTF) guidelines at 100%, no deductible, no copay at participating pharmacies only. Member must have a prescription.
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