PURMS

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Details

 

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

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.