| Plan
Details |
Dental |
|
| POLICY
# |
PURMS13 |
|
| EFFECTIVE
DATE |
1/1/2001 |
|
| MEDICAL |
| |
NETWORK |
NON-NETWORK |
| DESCRIPTION |
In Network |
Out of Network |
| Alternative
Health Care |
100% after $15 copay |
90% after $30 copay |
| Annual
Deductible |
None |
None |
| Annual Out of Pocket |
$750/person/year |
$750/person/year |
| $1,500/family/year |
$1,500/family/year |
| Ambulance
Services |
|
|
| Air
Ambulance |
100% after $100 copay |
100% after $100 copay |
| Ground
Ambulance |
100% after $50 copay |
100% after $50 copay |
| Ambulatory
Surgical center |
100% after $15 copay |
100% after $30 copay |
| Chemical
Dependency Services |
$10,326 per 24 consecutive
calendar month period |
$10,000 per 24 consecutive
calendar month period |
| Inpatient |
100% subject to hospital
copay |
90% subject to hospital
copay |
| Outpatient |
100% after $15 copay per
visit |
90% after $30 copay per
visit |
| Diabetic
Education |
100% after $15 copay per
visit |
100% after $30 copay per
visit |
| Diagnostic
Testing, Laboratory and X-ray |
100% |
100% |
| Durable
Medical Equipment, Supplies And Prostheses |
90% |
60% |
| Emergency
Room Services (Copay waived if admitted directly from emergency room |
100% after $50 copay per
visit |
90% after $50 copay per
visit |
| Hearing
Care |
|
|
| Routine
Exam |
100% after $15 copay per
exam |
90% after $30 copay per
exam |
| Hardware |
100%; maximum of $300 every
36 months |
100%; maximum of $300 every
36 months |
| Home
Health and Hospice Care |
100% |
90% |
| Hospital
Inpatient Services |
|
|
| Inpatient
Facility services |
100% after $100 copay per
day; maximum $300 per person per year |
100% after $100 copay per
day; maximum $300 per person per year |
| Inpatient
professional services |
100% |
100% |
| Mammograms |
100% |
100% |
| Mental
Health Care |
|
|
| Inpatient |
80% to 10 days per year |
50% to 10 days per year |
| Outpatient |
50% to 20 visits per year |
50% to 20 visits per year |
| Neurodevelopmental
Therapy For Children Age 6 and Under |
|
|
| Inpatient
– 60 days per year |
100% subject to hospital
copay |
100% subject to hospital
copay |
| Outpatient
– 60 visits per year |
100% after $15 copay per
visit |
90% after $30 copay per
visit |
| Obstetrical
Care |
|
|
| Inpatient
facility services |
100% subject to hospital
copay |
100% subject to hospital
copay |
| Professional
inpatient and Outpatient services |
100% after $15 copay per
visit |
100% after $30 copay per
visit |
| Office
and Clinic visits |
100% after $15 copay per
visit |
100% after $30 copay per
visit |
| Organ
Transplants |
|
|
| Inpatient
facility services |
100% subject to hospital
copay |
90% subject to hospital
copay |
| Inpatient
professional services |
100% |
90% |
| Outpatient
/ Day surgery |
100% after $15 copay per
visit |
100% after $30 copay per
visit |
| Physical,
Occupational and speech Therapies |
|
|
| Inpatient
– 60 days per year |
100% subject to hospital
copay |
90% subject to hospital
copay |
| Outpatient
– 60 visits per year for all therapies combined |
100% after $15 copay per
visit |
90% after $30 copay per
visit |
| Prescription
Drugs, Insulin and Diabetic Supplies |
|
|
| Retail
– Up to a 30-day supply |
|
|
| All
generic drugs, insulin and Diabetic supplies |
100% after $10 copay per
prescription or refill |
100% after $10 copay per
prescription or refill |
| Name-brand |
100% after $20 copay per
prescription or refill |
100% after $20 copay per
prescription or refill |
| Generic
and name-brand drugs Mail-order – up to 90-day supply |
100% after $30 copay per
prescription or Refill |
100% after $30 copay per
prescription or Refill |
| Preventive
Care |
100% |
100% |
| Radiation-Chemotherapy |
100% |
100% |
| Skilled
Nursing Facility; 150 days per Year |
100% subject to hospital
copay |
90% subject to hospital
copay |
| Spinal
Manipulations; |
100% after $15 copay per visit |
90% after $30 copay per visit |
| Maximum
12 visits per year |
| Tobacco
Cessation Services |
|
|
| Tobacco
cessation program |
Up to $350 per insured per
calendar year |
Up to $250 per insured per
calendar year |
| Tobacco
cessation prescription drugs |
Up to $350 per insured per
calendar year |
Up to $250 per insured per
calendar year |
| Temporomandibular
Joint Dysfunction (TMJ) Surgical Treatment Only |
50% to $1,000 per year |
50% to $1,000 per year |
| Vision
Care (routine) |
|
|
| Routine
Eye Exams: one exam each calendar year |
100% after $15 copay per
exam |
100% after $30 copay per
exam |
| Hardware
each 2 calendar years: |
100% to $400 maximum |
100% to $400 maximum |
| Lasik
Eye Surgery each 5 calndar years: |
100% to $800 maximum |
100% to $800 maximum |
| ADDITIONAL
FEATURES |
|
|
| Human Growth Hormone |
80% |
80% |
| DENTAL SERVICES |
| Diagnostic/preventive |
100% |
| INCLUDES |
oral exam (two exams in a 12 month period) -
x-rays (a complete series of intra-oral films & panoramic films limited to once in any 12 month period)
PROPHYLAXIS (limited to two treatments in any 12 month period, FLUORIDE (for
persons under 15), ORAL HYGIENE INSTRUCTIONS (limited to 3 sessions), PLASTIC
SEALANTS (for permanent teeth), SPACE MAINTAINERS |
| Restorative
fillings |
80% |
| INCLUDES |
AMALGAMS
& COMPOSITES, (composites covered on teeth anterior to the first
molar otherwise, amalgam apply allowances apply), GOLD FOIL RESTORATIONS,
EXTRACTIONS, ANESTHESIA (local anesthesia included in allowance for
procedure) NO benefits for nitrous oxide, ENDODONTICS (direct pulp capping,
pulpotomy & root canal therapy, apicoectomy and root resections, repair
of relining of dentures, recementing onlays or crowns, repair or recementing
bridges, ORAL SURGERY (root surgery, alveoplasty, replantation, removal of
odontogenic cyst and incision and drainage of abscesses and surgical
extractions) PERIODONTAL procedures (exam, scaling & root planing,
occlusal adjustment and guards (bite guards), gingivectomy and gingivoplasty
(gum surgery), gingival curettage (scraping of gums) osseous (bone) surgery |
| Oral
surgery |
80% |
| Periodontic
services |
80% |
| Endodontic
services |
80% |
| Restorative
crowns |
60% |
| INCLUDES |
GOLD
INLAY RESTORATIONS, CROWNS (plastic, porcelain, stainless steel, nonprecios
metal, gold) (Porcelain crowns covered only on teeth anterior to first molar:
otherwise, the metal allowance is provided), TEMPORARY DENTURES, TISSUE
CONDITIONING PROSTHETICS (for replacement of anterior teeth extracted with
the previous 30 days - no other temporary prosthetics provided). TEMPORARY
CROWNS (for immediate out-of-area emergency treatment only - no other
temporary crowns provided). PROSTHETICS (including bridges, dentures or
partials) |
| Prosthodontic
(dentures and bridges) |
60% |
| INCLUDES |
GOLD
INLAY RESTORATIONS, CROWNS (plastic, porcelain, stainless steel, nonprecios
metal, gold) (Porcelain crowns covered only on teeth anterior to first molar:
otherwise, the metal allowance is provided), TEMPORARY DENTURES, TISSUE
CONDITIONING PROSTHETICS (for replacement of anterior teeth extracted with
the previous 30 days - no other temporary prosthetics provided). TEMPORARY
CROWNS (for immediate out-of-area emergency treatment only - no other
temporary crowns provided). PROSTHETICS (including bridges, dentures or
partials) |
| Orthodontic
(to lifetime Maximum Plan payment of $1,500) |
70% |
| Nonsurgical
TMJ (to lifetime maximum Plan payment of $1,000) |
70% |
| Orthognathic
(to lifetime maximum Plan payment of $5,000) |
70% |
|
|
|