Item |
|
|
Calendar Year Deductible |
|
|
Individual |
None |
$100 |
Family |
None |
$200 |
Co-Insurance |
|
|
Maximum Out-of-Pocket |
|
|
Individual |
$1,000 |
$1000
after deductible |
Family |
$1,000 |
$1000
after deductible |
Lifetime Maximum Policy Coverage |
$2,000,000
(combined) |
Hospital Services |
|
|
Hospital Pre-Certification |
Required
by Physician |
Required
by Physician |
Hospital
Room & Board |
100% |
80%
after deductible |
In-Patient Surgery |
100% |
80%
after deductible |
Pre-Admission
Testing |
100% |
80%
after deductible |
Emergency
Room - Accident or Illness |
100% |
80%
after deductible |
Emergency
Room - Non-Accident or Non-Emergency |
90% |
80%
after deductible |
Emergency
Care - Physician |
100% |
80%
after deductible |
Diagnostic
X-Ray & Lab |
100% |
80%
after deductible |
Physician Services |
|
|
Doctor
Office Visits (medically necessary) |
100%
after $5 co-payment |
80%
after deductible |
Outpatient
and Home Visits |
100% |
80%
after deductible |
Pre & Post
Natal Care |
100% |
80%
after deductible |
Allergy
Testing and Therapy |
100% |
80%
after deductible |
Chiropractic
Care
|
100%
after $5 co-payment |
80%
after deductible |
Limited
to 30 visits/calendar yr. |
Limited
to 30 visits/calendar yr.
80%
after deductible |
Out-Patient
Surgery |
100% |
Preventative Services |
|
|
Routine
Physical Exams
|
$100
Benefit for member and spouse |
$100
Benefit for
member and spouse |
otherwise
not covered |
otherwise
not covered |
GYN
Exams |
100%
- 1 per 12 months |
80%
after deductible -
1 per 12 months |
Well
Child Care |
Covered
up to age 6 |
Not
covered |
Immunizations |
Covered
up to age 6 |
Not
covered |
Routine
Pap Smear |
|
80%
after deductible -
1 per 12 months |
Routine
Mammogram |
|
80%
after deductible -
Age 35 or older |
Mental & Nervous |
|
|
In-Patient
|
100% - Maximum of
60 days per calendar
year
|
80%
after deductible subject toMaximum
of 60 days
per calendar year
|
Out-Patient
|
60%
-Maximum of
50 visits per calendar year
|
60%
after deductible subject to
Maximum
of 50 visits
per calendar year
|
Substance Abuse |
|
|
In-Patient
|
100%
- Maximum of
60 days per calendar year
|
80%
after deductible subject to
Maximum of 60 days
per calendar
year
|
|
60%
-Maximum of
50 visits per calendar year |
60%
after deductible subject to
Maximum of 50 visits
per calendar year |
Other Services |
|
|
Prescription
Drugs - Script Guide- Nationwide
|
Generic
- $1.00 copay |
75%
of usual & customary |
Brand
Name - $5.00 copay |
after
copays |
Ambulence
Services |
90% |
80%
after deductible |
Durable
Medical Equipment |
90% |
80%
after deductible |
Prosthetics
and Orthotics |
90% |
80%
after deductible |
Home
Health Care |
100% |
80%
after deductible |
Miscellaneous |
|
|
Pre-Existing
Condition Definition |
Not
Applicable |
Not
Applicable |
Pre-Existing
Condition Limitation |
Not
Applicable |
Not
Applicable |
|
Spouse;
Child to 12/31 of year turns 19,
or to 12/31 of year
turns 25 if still
|
Definition
of Dependent |
dependent
as defined by the IRS
(family continuation charge
after 19)
|
Accidental
Injury Benefit (for services not normally covered
at 100%) |
100%
for first 60
days from accident |
80%
after deductible |
Out
of Network - Vacation out of State |
100% |
100% |
Lasik
Eye Surgery |
100% |
80%
after deductible |
Additional
Benefits |
|
|
Well Baby Care - up to age 6
|
100% including immunizations
|
Not
Covered |
