| 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) |
| 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
/ fittings for contacts are NOT covered |
| Lenses
- frames - contacts |
100% every 24 months frames - 12 months 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 |
|
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