| Details |
Dental |
|
| |
Preferred Network |
Out of Network |
| COPAY |
$10 |
$10 |
| After
copay and applicable deductible Plan will pay |
90% |
70% |
| INDIVIDUAL
DEDUCTIBLE
Per calendar year. |
$0 |
$100 |
| FAMILY
DEDUCTIBLE
Per calendar year. |
$0 |
$300 |
| INDIVIDUAL
MAXIMUM OUT-OF-POCKET EXPENSE Per calendar year. |
$400 |
$1,200 |
| FAMILY
MAXIMUM OUT-OF-POCKET EXPENSE Per calendar year. |
$3,000 |
| ALLERGY
INJECTIONS
Copay waived when services of physician not required. |
90% |
70% |
| ALLERGY
TESTING |
90% |
70% |
| ALTERNATIVE
SERVICES $1,000 combined maximum per
calendar year. Accupuncture, massage therapy and/or
registered dietitian services |
90% |
70% |
| AMBULANCE
(AIR AND GROUND) |
90% |
90% |
| ANESTHESIOLOGIST |
90% |
70% |
| ASSISTANT
SURGEON |
90% |
70% |
| CHEMICAL
DEPENDENCY TREATMENT Maximum of $5,000 during 24
consecutive months. Lifetime maximum of $10,000. |
90% |
70% |
| CHIROPRACTIC
SERVICES AND X-RAYS Limited to $500 per calendar
year. |
90% |
70% |
| DIAGNOSTIC
TESTING |
90% |
70% |
| DIETARY
EDUCATION Combined maximum - see Alternative
Services |
90% |
70% |
| DURABLE
MEDICAL EQUIPMENT |
90% |
90% |
| EMERGENCY
ROOM SERVICES Copay waived if admitted as a patient
and if emergency treatment is for life threatening condition, if directly
referred to emergency room by family physician and if services are obtained
from hospital outpatient clinic. |
$50 Copay then 90% |
$50 Copay then 70% |
| HEARING
BENEFIT Maximum payment of $500 in any 36
consecutive months. |
90% |
70% |
| HOME
HEALTH CARE Limited to 130 visits per calendar year. |
90% |
70% |
| HOSPICE
CARE Lifetime maximum 10,000. |
100% |
100% |
| INFERTILITY
TREATMENT |
0% |
0% |
| INFUSION
THERAPY |
90% |
70% |
| INPATIENT
PHYSICIAN VISIT |
90% |
70% |
| MEDICAL
FACILITY SERVICES |
90% |
70% |
| MENTAL
TREATMENT |
|
|
| Inpatient
- Limited to 10 days maximum per calendar year. |
90% |
70% |
| Outpatient
- Limited to 30 visits per calendar year. |
50% |
50% |
| NEURODEVELOPMENTAL
THERAPY Limited to dependent children up to age six. |
90% |
70% |
| OFFICE
VISIT |
90% |
70% |
| PHYSICAL,
OCCUPATIONAL & SPEECH THERAPY |
90% |
70% |
| PREVENTIVE
CARE Adult benefit limited to $500 per calendar
year. |
90% |
70% |
| REHABILITATION
SERVICES |
|
|
| Inpatient
- limited to 60 days per calendar year. |
100% |
N/A |
| Outpatient
Services |
90% |
70% |
| SECOND
SURGICAL OPINION The Plan will pay 100% of UCR if
second opinion is required as part of Plan's medical review process. |
90% |
70% |
| SKILLED
NURSING FACILITY |
90% |
70% |
| TOBACCO
CESSATION Lifetime maximum $300. |
90% |
70% |
| TEMPOROMANDIBULAR
JOINT DISORDER Lifetime maximum $500. |
70% |
70% |
| TRANSPLANTS |
90% |
0.00% |
| PRESCRIPTION BENEFITS |
| PCN
Client Based Network pharmaceuticals |
|
|
| Generic
Drugs |
$ 5 Copay |
|
| Brand
name Drugs |
$15 Copay |
|
| Dispensing
limit 34 days. |
|
|
| Maintenance
Drugs - Neil's Pharmacy |
|
|
| Generic
Drugs |
$ 5 Copay |
|
| Brand
Name Drugs |
$15 Copay |
|
| Dispensing
limit 100 days. |
|
|
| DENTAL BENEFITS |
| INDIVIDUAL
DEDUCTIBLE Per calendar year. Waived for preventive
services. |
$25 for Class II & III |
|
| MAXIMUM
PAYABLE |
|
|
| During
each 12 month period, Jan 1 - Dec. 31. |
$2,000 per person |
|
| Class
I benefits - Preventive Oral
Exam, Cleaning, X-rays, Fluoride, Sealants. Deductible waived. |
100% |
|
| Class
II benefits - Basic and Restorative
Fillings, Oral Surgery, Endodontic Treatment, Periodontal Services. |
80% |
|
| Class
III benefits - Major and Prosthetics
Bridgework, Crowns, Dentures and their repairs. |
75% |
|
| ORTHODONTIA Lifetime maximum $1500. Deductible does not apply. |
50% |
|
| ORTHOGNATHIC
SURGERY Lifetime maximum $5,000. |
70% |
|
| TEMPOROMANDIBULAR
JOINT (TMJ) Lifetime maximum $500 |
70% |
|
| VISION BENEFITS |
| EYE
EXAM Limited to one exam per calendar year. |
100% |
|
| Lenses,
Frames and Contact Lenses. Benefit limited per calendar year. |
$300 |
|
|
|
|