| Full Plan Details |
Dental |
| POLICY # |
PURMS05 |
| EFFECTIVE
DATE |
5/1/2000 |
| Deductible |
$100 per person / $300 per
family |
| Deductible
carryover |
YES |
| Coinsurance
Limit |
$5,000 per person / $10,000 per
family eligible expenses which have been paid at 80% / physicals - mental
health - substance abuse - and 50% benefits DO NOT APPLY |
| Lifetime
Maximum |
unlimited |
| PHYSICIAN
BENEFITS |
|
| Office
Visit |
80% of covered services, after
deductible |
| Employee/spouse physical |
80% of covered services, one
exam per person per year, $250 maximum allowable charge |
| Outpatient
Surgery |
100% of covered services |
| Inpatient
& Office Surgery |
80% of covered services, after
deductible |
| Hospital
visits & Services |
80% of covered services, after
deductible |
| Second
Surgical Opinion |
100% of covered services only if
preauthorized - otherwise 80% of covered services, after deductible |
| Allergy
immunizations |
80% of covered services, after
deductible |
| HOSPTIAL
BENEFITS |
|
| Inpatient
/room anesth. misc. |
100% of the first $5,000 of
covered, then 80% of the covered services |
| Outpatient
Surgery - Fac. Fee |
100% of the first $5,000 of
covered for surgery at a hospital outpatient basis, a free-standing surgical
facility, or an approved ambulatory surgical center otherwise, 80% of covered
services |
| Emergency Room |
Accident: 100% of covered
expenses within 72 hours of injury |
| Illness:
80% of covered services after deductible |
| Diagnostic lab & x-ray |
80% of covered services, after
deductible |
| 100% of
the first $5,000 of covered services for pre-admission testing within 10 days
of inpatient confinement or outpatient surgery |
| Mental
Health - |
|
| Substance
Abuse |
100% of the first $5,000 of
covered services, then 80% of covered services, maximum lifetime benefits of
120 days inpatient care |
| Inpatient
care - hospital |
This $5,000 limit includes all
expenses incurred during a hospital stay including: operating room - x-rays -
lab test - medicine - anesthetics - ambulance services - and pre-admission
x-ray/lab tests. Outpatient hospital
expenses for emergency care within 72 hours of an accident or surgery are
also included in the $5,000 limit per confinement. |
| Outpatient
care - physician |
80% of covered services, after
deductible; maximum 50 visits per year, $100 per visit maximum allowable
charge |
| Other
Medical Benefits |
|
| Supplemental
accident |
100% of covered services within
90 days of an accident, $300 maximum benefit per accident; then 80% after
deductible |
| Chiropractic
care |
80% of covered services, after
deductible, visits beyond 30 per year require pre-certification |
| Physical
& speech therapy |
80% of covered services, after
deductible |
| Durable
medical equipment |
80% of covered services, after
deductible |
| Ambulance |
100% of the first $5,000 of
covered services if due to an accident within 72 hours of injury or resulting
in an emergency hospital admission; otherwise, 80% of covered services, after
deductible |
| Hearing
aids |
80% of covered services, after
deductible; $750 maximum allowable charge; due to surgery or traumatic injury
only |
| Private
duty nursing |
80% of covered services, after
deductible; $10,000 maximum eligible charges per year |
| Home
health care |
80% of covered services, after
deductible; 4 hours per visit; 60 visits per year; for limited conditions |
| Convalescent nursing |
100% of the first $5,000 of
covered services per confinement, then 80% of covered services; maximum daily
limit equal to 80% of |
| Convalescent nursing |
Semi-private room rate of last
confinement; maximum 90 days per cause |
| Hospice
care |
|
| Inpatient
hospice |
100% of covered services, $150
limit per day; maximum $3,000 per period of care |
| Outpatient
hospice |
100% of covered services;
maximum $2,000 per period of care |
| Bereavement |
$200 per family unit |
| Frames |
100% of covered services;
maximum 1 set every 24 months; maximum $60 benefit |
| Prescription
Drug benefit |
|
| Mail
service |
up to a 90 day supply |
| Generic
drug |
$10 co payment |
| Brand
name (req. by physician) |
$20 co payment |
| Brand
name - Patient's choice, when generic is available |
$10 co payment, plus difference
in cost between generic and brand name drug |
| Local
Pharmacy - network |
|
| Generic
drug |
$10 co payment |
| Brand
name (req. by physician) |
$15 co payment |
| Brand
name - Patient's choice, when generic is available |
$10 co payment, plus difference
in cost between generic and brand name drug |
| Retail
Pharmacy-non network |
Same as local pharmacy, but
patient must pay difference in cost between network plan cost and retail cost |
| Vision
benefits |
|
| eye exam |
100% of eligible charges - max one exam every 12
months |
| lenses
or contacts (1) |
100% of eligible charge max two lenses every 12
months |
| disposable contact lenses (1) |
100% of eligible charges - up to
a 12 month supply - every 12 months |
| frames |
100% of eligible charges, max
one set every 24 months - max $60 benefit |
| (1)
benefit is limited to either 2 lenses OR 2 contact lenses OR a 12 month
supply of disposable contact lenses every 12 months. A 12 month supply is
defined by the specific manufacturer's recommended usage guidelines. |
|
| DENTAL |
|
| DEDUCTIBLE |
$50 ON MAJOR SERVICES ONLY |
| PRE-DETERMINATION
REQUIRED |
NO - BUT RECOMMENDED |
| MAXIMUM
PAYABLE |
$2,000 |
| PREVENTIVE |
|
| INCLUDES |
EXAMS - PROPHY - FLUORIDE -
X-RAYS - SEALANTS - DIAGNOSTIC CASTS/STUDY MODELS |
| ORAL
EXAMS |
100% NOT MORE THAN TWO TIMES PER
YEAR |
| FULL
MOUTH X-RAY FREQUENCY |
100% NOT MORE THAN ONCE EVERY 3
YRS |
| BITEWINGS
FREQUENCY |
100% NOT MORE THAN TWO TIMES PER
YEAR |
| PROHPY
FREQUENCY |
100% NOT MORE THAN TWO TIMES PER
YEAR |
| FLUORIDE
FREQUENCY |
100% ONCE PER YEAR |
| FLUORIDE
TO AGE |
CHILDREN UNDER 18 |
| SEALANTS |
COVERED ON PERMANENT MOLARS - 2
APPLICATIONS - SEPARATED BY 48 MONTHS |
| SEALANTS
TO AGE |
UNDER AGE 19 |
| BASIC/RESTORATIVE |
|
| INCLUDES: |
FILLINGS - ENDODONTICS -
PERIODONTICS- DENTURE REPAIRS & ADDING TEETH - GENERAL ANESTHESIA - ORAL SURGERY - RECEMENT
INLAY/CROWNS/BRIDGES - PINS - SPACE MAINTAINERS * |
| PERIO -
HOW IS IT COVERED? |
80% SCALING LIMITED TO 4
QUADRANTS (OF EACH) PER YEAR |
| BASIC
RESTORATIVE PERCENTAGE |
80% |
| BITEGUARD
COVERAGE |
NONE |
| MAJOR |
|
| INCLUDES |
CROWNS - BRIDGES - PONTICS -
DENTURES |
| MAJOR PERCENTAGE |
50% |
| DEDUCTIBLE |
$50 |
| RESTRICTIONS |
MUST BE 5 YEARS SINCE LAST
PLACEMENT |
| ORTHODONTICS |
NO DEDUCTIBLE / 50% / LIFETIME
MAXIMUM BENEFIT IS $2,000 |
| LIMITATIONS/WAITING
PERIODS |
YES - IF
ELIGIBLE FOR COVERAGE AND YOU DON'T ENROLL |
| MISSING
TOOTH CLAUSE? |
NO IF ENROLLED ON 5-1-2000 / YES
IF EFFECTIVE ON ANY OTHER DATE |
|
|