PURMS

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Asotin County PUD Plan Summary
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