| Plan Detail |
Dental |
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| POLICY
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PURMS03 |
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| EFFECTIVE DATE |
4/1/2000 |
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| Deductible |
$125.00 per person / $375 per
family / Carry over - YES |
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| In Network |
90% of negotiated fees |
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| Out of Network |
80% of covered expenses |
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| Out of Pocket |
$500 in network fees - $1,000 combined in
network and out of network |
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| Hospital - Inpatient |
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| Hospital - Inpatient -
Maternity |
48 hr stay vaginal delivery / 96
hr stay cesarean section (Mom and baby
both) |
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| Hospital - Maternity - Early
Discharge |
allow 2 post discharge visits /
1 must be a home visit |
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| Hospital Psych/Substance Abuse
IN |
inpatient 30 days per year
covered / 2 partial days = 1 inpatient day |
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| Hospital Psych/Substance Abuse
OUT |
50% of $80 / 52 visits per yr /
per person |
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| Psych & Substance Other |
50% for testing and
prescriptions |
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| Psych & Substance Lifetime
Maximum |
$25,000 in and out-patient
combined limits apply whether PPO providers or not |
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| Maximum Benefit |
$2,000,000 for any 1 injury
/ sickness or pregnancy / during a
lifetime can fully restore benefit if no treatment for 24 months or proof of
good health |
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| Common Accident Feature |
If 2 or more family members are
injured in the same accident - no deductible will apply for that year or the
next year except if the charges are not related to the accident |
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| Private Duty Nursing |
$125 per day limit - must be
licensed nurse providing the service |
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| Reconstructive Surgery |
covered following a mastectomy |
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| Emergency Transportation |
rail - ambulance - plane
maximum $2,500 per confinement |
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| Rental or Purchase Medical
Equip. |
$10,000 person's lifetime
(wheelchair - bed - iron lung …) |
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| Mammogram Screening |
One per calendar year by
recommendation of a Dr, Nurse or PA aides up to 20 hours per week |
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| Home Health Care |
must have a written plan by a
doctor / confinement in a hospital would
be required if if home health
care were not provided / under continuous care by that doctor |
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| Convalescent Care Facility |
50% of the most common
semi-private room from the hospital they just left. 90 days for any 1 injury
or sickness. Must be inpatient for 3 days in a row prior to confinement,
prior confinement must be covered. Must enter within 7 days of leaving the
hospital. Stay must result from the same injury or sickness. Doctor who saw
them in the hospital must recommend - approve and supervise care |
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| A new 3
day stay must precede a later period of care if totally unrelated or more
than 7 days after discharge or after normal duties resume |
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| Hospice Care |
Must be terminal with 6 months
or less to live, benefits can be extended if Dr. recertifies that person has
6 months or less to live & recommends admission into the hospice program |
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| Bereavement
benefits - lifetime maximum 3 months
following the death of a family member |
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| Treatment of feet |
$2,000
per cal yr for: an open cutting operation / the removal of nail roots /
treatment of weak, strained, unstable or unbalanced feet, metatarsalgia or
bunions or corns calluses or toenails if you have a metabolic or peripheral
vascular disease |
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| Pre-Existing Conditions |
Injury
/ sickness or pregnancy for which the covered person consulted a doctor, took
medicine, or received other medical care or advice within 12 months before
becoming covered or existence of symptoms which would cause an ordinary
prudent person to seek advice, diagnosis or are or treatment within 12 months
before becoming covered. Expenses will
be covered after you are covered for 6 months in a row |
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| Chiropractic adjustments |
$500 per person - per calendar
year payable |
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| Confinement when coverage
terminates |
If confined - covered until the
date discharged - 3 months from date the coverage ended or the date the
maximum has been paid |
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| Second Surgical Consultation |
Must be within 90 days of when
surgery was recommended - must take place prior to entering the hospital for
the surgery - procedure must be done only on a hospital inpatient basis -
specialist must examine the covered person in person. 100% of covered expense
paid up to $100 no deductible (rest is major medical) for
visit - x-rays and lab work, two consultations can be covered for any one
procedure by a different specialist. Doctor must have a surgical specialty
for which surgery is recommended / can not do the second opinion and the
surgery |
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| VISION |
$150 per person
per calendar year for hardware and exams combined |
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| DENTAL |
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| DEDUCTIBLE |
$50 FOR BASIC AND/OR MAJOR |
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| PRE-DETERMINATION
REQUIRED |
N0 - BUT RECOMMENDED |
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| MAXIMUM
PAYABLE |
$1,000 PER PERSON / PER CAL YEAR |
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| PREVENTIVE |
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| INCLUDES |
EXAMS - PROPHY - FLUORIDE -
X-RAYS - SPACE MAINTAINERS - STUDY MODELS/DIAGNOSTIC CASTS |
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| DEDUCTIBLE |
NONE |
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| ORAL
EXAMS |
80% NOT MORE THAN ONCE EVERY 6
MONTHS |
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| FULL
MOUTH X-RAY FREQUENCY |
80% NOT MORE THAN ONCE EVERY 3
YRS |
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| BITEWINGS
FREQUENCY |
80% NOT MORE THAN ONCE EVERY 6
MONTHS |
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| PROHPY
FREQUENCY |
80% NOT MORE THAN ONCE EVERY 6
MONTHS |
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| FLUORIDE
FREQUENCY |
80% ONCE PER YEAR |
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| FLUORIDE
TO AGE |
19 |
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| SEALANTS |
COVERED ON PERMANENT MOLARS |
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| SEALANTS
TO AGE |
AGES 6 TO UNDER AGE 19 |
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| BASIC/RESTORATIVE |
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| INCLUDES |
FILLINGS
- ENDODONTICS - PERIODONTICS - DENTURE REPAIRS - ORAL SURGERY - OFFICE VISITS
- APPLIANCE TO CORRECT THUMBSUCKING - EMERG. PALLIATIVE TREATMENT - SPEC.
CONSULT |
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| PERIO -
HOW IS IT COVERED? |
80% SCALING NOT MORE THAN ONCE
EVERY 6 MONTHS |
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| BASIC
RESTORATIVE PERCENTAGE |
80% |
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| BASIC
RESTORATIVE DEDUCTIBLE |
$50.00 |
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| BITEGUARD
COVERAGE |
YES - $50 DEDUCTIBLE 80% |
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| MAJOR |
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| INCLUDES |
CROWNS - BRIDGES - PONTICS -
DENTURES |
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| MAJOR PERCENTAGE |
50% |
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| DEDUCTIBLE |
$50 |
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| RESTRICTIONS |
MUST BE 5 YEARS SINCE LAST
PLACEMENT |
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| ORTHODONTICS |
NO DEDUCTIBLE / 50% / TO A
LIFETIME MAXIMUM PAYABLE OF $500 |
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| LIMITATIONS/WAITING
PERIODS |
YES - IF
ELIGIBLE FOR COVERAGE AND YOU DON'T ENROLL |
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| MISSING
TOOTH CLAUSE? |
NO IF ENROLLED ON 4-1-2000 / YES
IF EFFECTIVE ON ANY OTHER DATE |
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