| |
In-Network |
Out-of-Network |
| Deductible per Covered Person, per Calendar Year |
$1,700 |
$2,000 |
| Deductible per Family Unit, per Calendar Year |
$3,400 |
$4,000 |
| Coinsurance |
100% - unless otherwise noted |
100% - subject to Usual & Customary (U & C) – unless otherwise noted |
| Lifetime Maximum Benefit per Covered Person while Covered Under this Plan |
$1,000,000 |
| Hospital Services |
| Inpatient Hospital |
After Deductible, 100% paid by Plan |
After Deductible, 100% paid by Plan subject to U & C |
| Hospital Outpatient Facility or Ambulatory Surgical Facility |
After Deductible, 100% paid by Plan |
After Deductible, 100% paid by Plan subject to U & C |
| Hospital Diagnostic X-ray & Lab |
After Deductible, 100% paid by Plan |
After Deductible, 100% paid by Plan subject to U & C |
| Extended Care Facility, Skilled Nursing Facility, Rehabilitation Facility |
After Deductible, 100% paid by Plan |
After Deductible, 100% paid by Plan subject to U & C |
| Emergency Room (when Emergency) |
After Deductible, 100% paid by Plan |
After Deductible, 100% paid by Plan subject to U & C |
| Emergency Room for Non-Emergency Services |
After Deductible, 100% (facility charge related to the non-emergency ER visit is limited to a $100 Maximum Benefit) |
| Precertification Requirements |
| This Plan requires all Non-Emergency Inpatient Admissions, Outpatient Surgeries, Non-Emergency surgical procedures and Outpatient Chemotherapy and Radiation Therapy to be precertified by calling Med-Cert at (800) 356-7126 prior to admission or treatment. It is recommended to call within 2 business days following an Emergency Admission or Surgery. Failure to precertify an inpatient admission or outpatient surgery results in a $250 penalty |
| Physician Services |
| Physician inpatient visits, inpatient or outpatient surgical, anesthesia, radiology, pathology or ER Physician |
After Deductible, 100% paid by Plan |
After Deductible, 100% paid by Plan subject to U & C |
| Physician Office Services Primary Care Physician or Specialist |
After Deductible, 100% paid by Plan |
After Deductible, 100% paid by Plan subject to U & C |
| |
In-Network |
Out-of-Network |
| Other Medical Services |
| Ambulance |
After Deductible, 100% paid by Plan |
After Deductible, 100% paid by Plan subject to U & C |
Maternity Services
(Employee/Spouse only) |
After Deductible, 100% paid by Plan |
After Deductible, 100% paid by Plan subject to U & C |
| Durable Medical Equipment |
After Deductible, 100% paid by Plan |
After Deductible, 100% paid by Plan subject to U & C |
| Prosthetic, Orthotic, Orthopedic Devices |
After Deductible, 100% paid by Plan |
After Deductible, 100% paid by Plan subject to U & C |
Hospice Services
(6 month life expectancy) |
After Deductible, 100% paid by Plan |
After Deductible, 100% paid by Plan subject to U & C |
| Home Health Care |
After Deductible, 100% paid by Plan |
After Deductible, 100% paid by Plan subject to U & C |
| Physical, Occupational or Speech Therapy |
After Deductible, 100% paid by Plan |
After Deductible, 100% paid by Plan subject to U & C |
Other Therapy Services
(chemotherapy, radiation, dialysis etc.) |
After Deductible, 100% paid by Plan |
After Deductible, 100% paid by Plan subject to U & C |
| Chiropractic Care (maintenance care is not covered) |
After Deductible, 100% paid by Plan |
After Deductible, 100% paid by Plan subject to U & C |
| TMJ/Jaw Joint Services |
After Deductible, 100% paid by Plan |
After Deductible, 100% paid by Plan subject to U & C |
| Organ & Tissue Transplants |
After Deductible, 100% paid by Plan |
After Deductible, 100% paid by Plan subject to U & C |
Preventative Care (Adult or Child)
Exams, Labs, Immunizations & Other Routine Services as recommended by the current CDC guidelines related to age & frequency |
No Deductible, 100% |
No Deductible, 100% paid by Plan subject to U & C |
| $1,500 Calendar Year Maximum per Covered Person |
| Preventative Colonoscopy and Sigmoidoscopyper the most current CDC guidelines regarding age & frequency |
No Deductible, 100% |
No Deductible, 100% paid by Plan subject to U & C |
| Mental Health and Substance Abuse Services |
| Mental Health Inpatient Services |
After Deductible, 100% paid by Plan |
After Deductible, 100% paid by Plan subject to U & C |
| |
In-Network |
Out-of-Network |
| Mental Health Outpatient Services |
After Deductible, 100% paid by Plan |
After Deductible, 100% paid by Plan subject to U & C |
| Substance Abuse Inpatient Services |
After Deductible, 100% paid by Plan |
After Deductible, 100% paid by Plan subject to U & C |
| Substance Abuse Outpatient Services |
After Deductible, 100% paid by Plan |
After Deductible, 100% paid by Plan subject to U & C |
Perscription Drugs
Please Note: Prescription Drug Copayments do not apply to the Deductible |
| Prescription Drug Copayments at a Participating Pharmacy for a 31-day supply, or 90-days (if maintenance medication) |
0% Generic Copayment, 100% |
| 10% Formulary Brand Copayment, 100% |
| 20% Non-Formulary Brand Copayment, 100% |
| Prescription Drug Copayments through the Mail Order Pharmacy for a 90-day supply |
0% Generic Copayment, 100% |
| 10% Formulary Brand Copayment, 100% |
| 20% Non-Formulary Brand Copayment, 100% |