| Details |
Dental |
|
|
IN THE PPO |
OUT OF THE PPO |
| LIFETIME
MAXIMUM MEDICAL BENEFIT |
$2,000,000 |
$2,000,000 |
| DEDUCTIBLES |
NONE |
NONE |
| MEDICAL OUT-OF-POCKET MAXIMUM |
| After
an individual has incurred $1,250 of eligible out-of-pocket medical expenses
in one calendar year, the Plan will pay 100% of the eligible charges
subsequently incurred by that individual in that calendar year. Hospital and
physician copayments do not apply toward your calendar year out-of-pocket
maximum. |
$400 |
$1,250 |
| HOSPITAL INPATIENT SERVICES |
|
| Room
and Board |
100% after $100 |
80% after $100 |
| Semiprivate
room |
copayment per day - |
copayment per day - |
| Intensive
care unit |
Maximum $300 |
Maximum $300 |
| Private
room (as medically necessary) |
copayment per |
copayment per |
| Operating
and recovery rooms |
admission |
admission |
| Special
unit and treatment rooms |
|
|
| Additional
Inpatient Services |
100% |
80% |
| Lab/x-ray
professional interpretive fees |
| Drugs,
anesthesia, and biologicals |
| Hemodialysis
and administration of blood |
| Blood
& blood plasma |
| Nursing
care |
| All
other medically necessary inpatient services |
| Inpatient
Rehabilitation |
100% |
80% |
| Physical,
occupational and speech therapy |
| HOSPITAL OUTPATIENT SERVICES |
| Hospital
or Special Facility Charges for Outpatient |
100% after $50 copayment |
80% after $50 copayment |
| Surgery |
| Hospital
Emergency Room Services |
100% after $100 |
80% after $100 |
| ($50
copayment waived for life threatening medical |
copayment per visit |
copayment per visit |
| emergencies
or within 48 hours of an accidental injury) |
|
|
| Pre-Admission
Testing |
100% |
80% |
| Hospital
Outpatient Care |
100% |
80% |
| Including
MRI, CT Scans, radium, radioisotope and |
| X-ray
therapy, chemotherapy and hemodialysis |
| PHYSICIAN SERVICES |
| Office,
Hospital, Facility or Home Visits |
100% after $15 |
80% after $15 |
| Specialty
care and consultations |
copayment per visit |
copayment per visit |
| In-office
physician diagnostic, x-ray and laboratory tests |
|
|
| In-office
minor surgical procedures |
|
|
| Injections
and allergy shots |
100% |
80% |
| Second
Surgical Opinions |
100% |
80% |
| X-ray
and Laboratory Services |
100% |
80% |
| Surgery |
100% |
80% |
| Anesthesiology
Services |
100% |
80% |
| Maternity
Care (Employee and Spouse only) |
Same as any other |
Same as any other |
| Prenatal
care, exams, tests and postnatal care |
medical condition |
medical condition out of PPO |
| Delivery
services |
|
|
| Newborn
and Well Baby Care |
|
|
| In
hospital exam at birth, including circumcision |
100% |
80% |
| |
|
|
| 5
additional exams in first year of life, including |
100% after $15 |
80% after $15 |
| immunizations
and vaccinations |
copayment per visit |
copayment per visit |
| |
|
|
| 2
exams in second year of life, including immunizations |
100% after $15 |
80% after $15 |
| and
vaccinations |
copayment per visit |
copayment per visit |
| Wellness
Care |
100% after $15 |
80% after $15 |
| Periodic
health evaluations |
copayment per visit |
copayment per visit |
| Prostate,
breast, pelvic exams, PAP smears |
|
|
| Immunizations
and vaccinations |
|
|
| Well
child care over age 2 |
|
|
| Mammography |
100% |
80% |
| Age
25 - 40 (one exam) |
| Over
age 40 (one exam per calendar year) |
| Family
Planning (Employee and Spouse only) |
100% |
80% |
| Sterilization
and voluntary termination of pregnancy |
| OTHER SERVICES AND SUPPLIES |
| Outpatient
Rehabilitative Care |
100% after $15 |
80% after $15 |
| Physical,
occupational, speech and audiological therapy |
copayment per visit |
copayment per visit |
| Alternative
Care |
100% after $15 |
80% after $15 |
| Includes
Naturopathic, acupuncture (medically necessary with referral) and massage
therapy (medically necessary with referral) Limited to $1,000 per calendar
year) |
copayment per visit |
copayment per visit |
| Chiropractic
Care |
100% after $15 |
80% after $15 |
| (Limited
to 30 visits per calendar year) |
copayment per visit |
copayment per visit |
| Naturopathic
Care |
100% after $15 |
80% after $15 |
| (Limited
to $500 per calendar year) |
copayment per visit |
copayment per visit |
| Neurodevelopmental
Therapy (Participants Under Age 7) |
100% after $15 |
80% after $15 |
| (Limited
to $2,500 lifetime maximum) |
copayment per visit |
copayment per visit |
| Skilled
Nursing Facility |
80% |
60% |
| (Limited
to 180 days per calendar year) |
| Home
Health Care Benefit |
100% |
80% |
| Organ
Transplant and Donor Benefit |
80% |
60% |
| (Subject
to specific limitations) |
| Phenylketonuria
(PKU) Formula |
100% |
80% |
| Durable
Medical Equipment, Supplies and Appliances |
80% |
60% |
| Treatment
for Mental Health and Psychiatric Services |
|
|
| Inpatient
care |
100% after $100 |
80% after $100 |
| |
copayment per day |
copayment per day |
| |
maximum copayment |
maximum copayment |
| |
$300 per admission |
$300 per admission |
| |
|
|
| Outpatient
care |
100% after $15 |
80% after $15 |
| |
copayment per visit |
copayment per visit |
| Treatment
for Obesity (excessive weight) |
80% |
Not Covered |
| Treatment
under this benefit must be preauthorized by the Plan Administrator.Benefits
are not subject to an will not apply to the out-of-pocket maximum. (Limited
to $25,000 lifetime maximum) |
|
|
| Treatment
for Chemical Dependency |
100% |
80% |
| (Limited
to $5,000 every 24 month period and $10,000 |
| lifetime
maximum) |
| Diabetic
Instruction |
80% |
60% |
| (Limited
to $250 lifetime maximum) |
| Cardiac
Rehabilitation |
80% |
60% |
| (Limited
to $2,500 per calendar year) |
| Special
Dental Care |
Same as any other medical condition |
Same as any other medical condition out of PPO |
| (Limited
to services incurred within 12 months of an accidental injury) |
| Temporomandibular
Joint (TMJ) Disorders |
Same as any other medical condition |
Same as any other medical condition out of PPO |
| (Limited to $2,000 lifetime maximum) |
| Hospice
Care |
100% |
80% |
| Ambulance
Transportation |
First $500 at 100%, then 80% |
First $500 at 100%, then 80% |
| |
|
|
|
| DENTAL BENEFITS |
Percentage or |
Percentage or |
| Amount
Paid |
Amount Paid |
| MAXIMUM
DENTAL BENEFIT - EVERY ONE CALENDAR YEARS |
$1,500 |
$1,500 |
| MAXIMUM
LIFETIME ORTHODONTIA BENEFIT |
$1,500 |
$1,500 |
| DEDUCTIBLE |
$25 Individual |
$25 Individual |
| $75
Family |
$75 Family |
| DENTAL
SERVICES |
|
|
| Class
I Services - Diagnostic and Preventive Care - Deductible Waived |
100% |
100% |
| Examination
(Limited to no more than once in any five-month period) |
| Prophylaxis
(Limited to no more than once in any five-month period) |
| Fluoride
treatments for participants under age 16 (Limited to no more |
| than
once in any five-month period) |
| Dental
X-rays, as required |
| Sealants |
| Space
maintainers |
| Emergency
palliative treatment |
| Bacteriologic
cultures and examination of oral tissue excised for biopsy |
| Class
II - Basic Services |
85% |
85% |
| Fillings |
| Oral
surgery |
| Root
canal therapy |
| General
anesthesia or local anesthetics with covered dental services |
| Repairs
and adjustments to bridges and dentures |
| Basic
periodontal services |
| Class
III - Major Services |
75% |
75% |
| Crowns |
| Inlays
and onlays |
| Bridges
and dentures |
| Major
periodontal services |
| Class
IV - Orthodontia Services - Deductible Waived |
50% |
50% |
| Consultation
and treatment plan |
| Cephalometric
film and orthodontic x-rays, as required |
| Removable,
fixed or cemented orthodontic appliances and adjustments |
|
|
|
|
|
|