PURMS

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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 $20 copay

90% after $40 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 $20 copay

100% after $40 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 $20 copay per visit

90% after $40 copay per visit

Diabetic Education

100% after $20 copay per visit

100% after $40 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 $20 copay per exam

90% after $40 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 $20 copay per visit

90% after $40 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 $20 copay per visit

100% after $40 copay per visit

Office and Clinic visits

100% after $20 copay per visit

100% after $40 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 $20 copay per visit

100% after $40 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 $20 copay per visit

90% after $40 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 $20 copay per visit

90% after $40 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 $20 copay per exam

100% after $40 copay per exam

Hardware each 2 calendar years:

100% to $400 maximum

100% to $400 maximum

Lasik Eye Surgery each 5 calndar years:

50% to $800 maximum

50% to $800 maximum

ADDITIONAL FEATURES

 

 

Human Growth Hormone

80%

80%

DENTAL SERVICES

Diagnostic/preventive

100%

INCLUDES

Examination is covered twice in a calendar year.  Complete series (four bitewing x-rays and up to ten periapical x-rays) or panorex x-rays are covered once every five years.  Supplementary bitewing x-rays are covered once every 12-months. prophylaxis (cleaning) is covered twice in a calendar year, fluoride is covered twice in a calendar year through age eighteen (18) when performed in conjunction with a prophylaxis 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%