PURMS

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Klickitat Benefits

Klickitat Benefits

Full Plan Dental
  IN THE PPO OUT OF THE PPO
LIFETIME MAXIMUM MEDICAL BENEFIT UNLIMITED UNLIMITED
     
ANNUAL MAXIMUM MEDICAL BENEFIT UNLIMITED UNLIMITED
DEDUCTIBLES Apply to all benefits except Preventive Care $125 Individual $125 Individual
   
$375 Family $375 Family
MEDICAL OUT-OF-POCKET MAXIMUM
After an individual has incurred the maximum amount of eligible out-of-pocket PPO medical expenses or eligible out-of-pocket non-PPO medical expenses in a calendar year, the Plan pays 100% of eligible charges subsequently incurred by that individual in that calendar year.  The maximum eligible out-of-pocket medical expenses is $2,000 (combination of PPO and non-PPO eligible expenses) in a calendar year.  Eligible expenses DO NOT include copayments associated with hospital and physician visits, prescription drug copayments, vision, or dental expenses. $1,000 $2,000
HOSPITAL INPATIENT SERVICES    
Room and Board 90% 80%
Semiprivate room
Intensive care unit
Private room (as medically necessary)
Operating and recovery rooms
Special unit and treatment rooms
Additional Inpatient Services 90% 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 90% 80%
Physical, occupational and speech therapy
HOSPITAL OUTPATIENT SERVICES    
Hospital or Special Facility Charges for Outpatient 90% 80%
Surgery
Hospital Emergency Room Services 90% after $50 80% after $50
($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 90% 80%
Hospital Outpatient Care 90% 80%
Including MRI, CT Scans, radium, radioisotope and
X-ray therapy, chemotherapy and hemodialysis
PHYSICIAN SERVICES    
Office, Hospital, Facility or Home Visits 90% after $10 80% after $10
In-office physician diagnostic, x-ray and laboratory tests copayment per visit copayment per visit
In-office minor surgical procedures    
Surgical consultations 90% after $20 copayment per visit 80% after $20 copayment per visit
Injections and allergy shots 90% 80%
Second Surgical Opinions 90% 80%
X-ray and Laboratory Services 90% 80%
Surgery 90% 80%
Anesthesiology Services 90% 80%
Preventive Care In accordance with the Affordable Care Act 100% 100%
Family Planning (Employee and Spouse only) 90% 80%
OTHER SERVICES AND SUPPLIES    
Outpatient Rehabilitative Care 90% after $10 80% after $10
Physical, occupational and speech therapy copayment per visit copayment per visit
Chiropractic Care 90% 80%
(Limited to $500 per calendar year)
Naturopathic Medicine 90% 80%
Acupuncture
Massage Therapy
Dietician
$500 combined annual limit
Skilled Nursing Facility 90% 80%
(Limited to 90 days per calendar year)
Home Health Care Benefit 90% 80%
Durable Medical Equipment, Supplies and Appliances 90% 80%
Treatment for Mental Health and Psychiatric Services and Chemical Dependency - Lifetime Maximum $25,000    
Inpatient care maximum 30 days 90% 80%
     
Outpatient care maximum 20 visits 90% after $10 80% after $10
  copayment per visit copayment per visit
Diabetic Instruction 90% 80%
(Limited to $250 lifetime maximum)
Special Dental Care Same as any other medical condition Same as any other medical condition out of PPO
(Limited to services incurred within 24 months of an accidental injury if treatment starts within 90 days)
Hospice Care 90% 80%
Ambulance Transportation 90% 80%
Air Ambulance 60% 60%
Organ Transplant and Donor Benefit (Subject to specific limitations) 90% 0%
DENTAL Percentage or
Amount Paid
MAXIMUM DENTAL BENEFIT -  EVERY CALENDAR YEAR $2,000
MAXIMUM LIFETIME ORTHODONTIA BENEFIT $2,000
DEDUCTIBLE $50 Individual
Applies to Class II and Class III Services only. $150 Family
DENTAL SERVICES  
Class I Services - Diagnostic and Preventive Care Deductible Waived 90%
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 subject to deductible 80% after deductible is met
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
Related oral exams
Class III - Major Services subject to deductible 75% after deductible is met
Crowns
Inlays and onlays
Bridges and dentures
Major periodontal services
Class IV - Orthodontia Services Deductible Waived 50%
Consultation and treatment plan
Cephalometric film and orthodontic x-rays, as required
Removable, fixed or cemented orthodontic appliances and adjustments