PURMS

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Plan Detail Dental
POLICY #  PURMS12
EFFECTIVE DATE 4/1/2000
Lifetime Maximum  $1,000,000 - reduced by $20,000 on January 1st of each calendar year
Annual deductible $75 per person, $225 per family, per calendar year
Deductible carry over YES
Co pays do not count toward deductible amount)
Out of Pocket $300 per person, per calendar year  /  the following do not count towards the stoploss: annual deductible amount, any co pays, the difference between the allowed amount & the provider's actual charge; any coinsurance required when the preadmission approval provision is not satisfied; and any balances that remain after benefits limits have been expended 
Physicians - participating 100% of the allowed amount for professional services - includes antigen and allergy vaccines
Alternative Providers 100% of the allowed amount / includes chiropractic / no limit (Per Rory 4-7-00) - Massage Therapy is limited to $1,000 per year per person
Pre-admission testing Preadmission testing for surgery paid at 100% of the allowed amount - within 48 hours prior to surgery @ the hospital that the surgery will be at
Hospital   
Room and board 85% of the allowed amt until eligible out of pocket expenses reach $300 per person, per calendar year - then 100% 
Skilled Nursing service 85% of the allowed amt until eligible out of pocket expenses reach $300 per person, per calendar year - then 100%
Name brand drugs 85% of the allowed amt  - no deductible - no out of pocket maximum (per Rory 4-7-00)
Home Medical equipment 85% of the allowed amt until eligible out of pocket expenses reach $300 per person, per calendar year - then 100%
Ambulance 85% of the allowed amt / air ambulance provided to the nearest hospital rquipped to render necessary treatment
Other special benefits 85% of the allowed amt until eligible out of pocket expenses reach $300 per person, per calendar year - then 100%
ambulatory surgical center 85% of the allowed amt  - copay does not apply for surgery in a hospital or ambulatory surgical center
Protheses & orthotics 85% of the allowed amt until eligible out of pocket expenses reach $300 per person, per calendar year - then 100%
Neurodevelopmental therapy **85% of the allowed amt / limit $2,000 per cal year - not subject to stop loss provision
Hospital Emerg. Room 85% after a $25 co pay for each visit to a hospital emergency room for illness, injury or surgery waived if admitted to the hospital as an inpatient (in addition to the annual deductible)
Maternity prenatal, postnatal, normal or cesarean delivery and voluntary termination of pregnancy treated as any other illness or injury - Only the subscriber or the subscriber's spouse are covered  - includes false labor - NOT subject to preexisting waiting periods - Dependent daughters do NOT have maternity coverage -  prenatal testing covered - see exclusions & limitations
Routine Physical 100% of the allowed amount per calendar year - no deductible - includes Well Baby exams (per Rory 3-29-00)
Vision care 100% - one eye exam per cal. year - not subject to the deductible or copay
Lenses - frames - contacts 100%  every 24 months frames - calendar year lenses - not subject to stop loss provision / no dollar limit
Special equipment & supplies 85% for: casts, colostomy bags and related supplies, formula for phenylketonuria will be provided at 100% of the allowed
  amount - not subject to any waiting periods - see exlusions and limitations
Mammography consider part of routine physical UNLESS there is a medical condition then covered under x-ray benefit (per Rory 3-28-00
Prescriptions 85% namebrand - 100% generic - limited to a 34 day supply or 100 units whichever is greater - insulin is covered see exclusions and limitations  - no limit - no deductible - no out of pocket maximum (per Rory 4-7-00)
Home Health & Hospice 90% - 130 home health visits per calendar year / see exclusions and limitations 
Infusion therapy 90% - maximum $25,000 per calendar year under this benefit and the home health &  hospice benefits combined not subject to stop loss provsions - see exclusions and limitations
Rehabilitative care Inpatient - Physician 100% / facility 85%  limited to $50,000 per condition - see exclusions and limitations
Outpatient -  85% to $2,000 per calendar year - not subject to stop loss provisions / see exclusions and limitations
Transplant 100% - see exclusions and limitations - $25,000 donor maximum per transplant if recipient is covered under this plan
Travel & lodging - for you & your family is covered when required to travel 30 miles or more outside of the service area for medically necessary services related to an approved transplant - Maximum is $2,500 per transplant episode - see exclusions and limitations 
Vol. Second Surgical Opinion paid in full - not subject to deductible or co pay WHEN performed by the physician referred to you, otherwise, subject to any deductible and co pay amount  and paid at the professional level (100%)
Family Accident deductible if two of more covered family members are injured in the same accident- only one deductible that year and the next year for charges incurred as a result of that accident Hospitalized from 1 year to the next - a second deductible will not be required for any treatment prior to your discharge from the hospital.  No additional coinsurance will be required for any treatment prior to discharge if you have met the stop loss limit for the calendar year in which the hospitalization began
Blood bank 85% of the servies of a recognized blood bank 
Diabetes care training 85% for outpatient training and education including nutritional therapy if recommended by an approved provider with
  expertise in diabetes
Home phototherapy 100% for newborn jaudice
Sterilization Procedures subject to waiting periods / reversals are NOT covered
Chemical Dependency 100% of the allowed amount  to $5,000 every two calendar years, to a lifetime maximum of $10,000 - any chemical depend.
  benfits provided during the previous 24 month period under this or any prior plan will be charged against the 2 yr benefit
Hearing aids 85% of the allowed amount to $2,000 every three years (not subject to deductible or stop loss) - must submit certification of hearing loss with your claim - see exclusions and limitations
Mental Health Inpatient paid at 80% of the allowed amount to 15 days per calendar year - not subject to the stop loss provision
outpatient paid at 50% of the allowed amount to 25 visits per calendar year - not subject to the stop loss provision
Smoking Cessation 75% of the allowed amount to a lifetime maximum of $500 - not subject to the stop loss provision - see exclusions and limitations
TMJ Treatment 50% to a lifetime maximum of $3,000 - see exclusions and limitations
Injury to teeth 100% of allowed mount only for repair of accidental injury to sound, natural teeth up to $600 per occurrence - see exclusions and limitations
DENTAL  
Preventive Services 100% coverage
INLCLUDES oral exam (not more than once in 6 months) x-rays - fluoride (to age 19 limited to once a 1 per yr  space maintainers (to under age 19) - fixed - removble-study models
DEDUCTIBLE  NONE
Basic Services 100% coverage      
INCLUDES Amalgam restorations - composite restorations - steel crowns - pulp capping - remineralization - pulpotomy - root canals - apicoectomy - gingivectomy - scaling and root planing - free soft tissue grafts - correction of occlusion related to periodontal problems - denture repairs - oral surgery (extractions, impacted teeth, surgical procedures, alveolar or gingival reconstruction, excisions of pericoronal gingivia-cysts-bone tissue-surgical incsion) - appliance to correct thumbsucking - emergency palliative treatment - anesthesia - special consultation - office visits  - post operative visit
DEDUCTIBLE  $50 (only ONE deductible (basic and major) per person)   Deductible is for TWO family members - per calendar year deductible
Major Services 50% coverage
INLAYS  (one, two, three or more surfaces) - CROWNS (acrylic, aryclic with gold, acrylic with metal, procelain, procelain with gold, porcelain with metal, gold , metal, 3/4 gold, steel post &   composite or amalgam in addition to crown) - RECEMENTATION  (inlay or crown) 
PROSTHODONTICS  (maxillary denture, mandibular denture) , Partial dentures (upper or lower without clasps, acrylic base - upper or lower with 2 clasps, acrylic base - upper or lower with bar and 2 clasps, acrylic or cast base, removable bridge - unilateral one piece casting, upper or lower - full cast with 2 clasps, each additional clasp with rest -Denture repairs (add tooth to partial to replace extracted tooth, each tooth involving or not involving a clasp or abutment tooth, replace damaged clasp, replace broken clasp, each additional clasp with rest - Denture rebasing, upper or lower, complete or partial (not more than once every 3 years) - denture relining (not more than once each year), upper or lower / complete or partial/office or lab, temporaty denture, special tissure conditioning, per denture (limited to two treatments per arch and more more than once each year) - Pontics (cast gold, cast metal, steele's facing, tru-pontic type, porcelain baked to gold,  porcelain baked to metal, plastic processed to gold, plastic processed to metal, repair or replace broken pontic Crowns - Abutments: (acrylic, acrylic with gold, acrylic with metal, porcelain, procelain with metal, gold (3/4 cast), gold (full cast), recement bridge, simple stress breakers.
DENTURES PARTIAL DENTURES AND RELINE PROCEDURES INCLUDE ADJUSTMENTS FOR 6 MONTH PERIOD FOLLOWING INSTALLATION.  CHARGES FOR SPECIALIZED TECHNIQUES AND CHARACTERIZATIONS ARE NOT COVERED DENTAL EXPENSES.
DEDUCTIBLE  $50 (only ONE deductible (basic and major) per person)      Deductible is for TWO family members - per calendar year
Orthodontic - 50% up to $500 lifetime. You must be covered for 180 days in row (to be eligible)  Paid in quarterly installments based on the length of time the dentist  estimates it will take to complete the course but not more than 2 years / covers: employee, spouse & children