PURMS

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Details Dental
IN THE PPO OUT OF THE PPO
LIFETIME MAXIMUM MEDICAL BENEFIT UNLIMITED UNLIMITED
ANNUAL MAXIMUM MEDICAL BENEFIT UNLIMITED UNLIMITED
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
($100 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
Chiropractic Care 100% after $15 80% after $15
(Limited to 30 visits per calendar year) copayment per visit copayment per visit
Naturopathic Medicine 100% after $15 80% after $15
See PHYSICIAN SERVICES above copayment per visit copayment per visit
Acupuncture 100% after $15 80% after $15
Medically necessary ($3,000 combined annual limit with Massage Therapy) copayment per visit copayment per visit
Massage Therapy 100% after $15 80% after $15
Medically necessary ($3,000 combined annual limit with Massage Therapy) 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 CALENDAR YEAR $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