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Plan Details Dental
Out of Pocket Amt $500 per calendar year then 100% of the reasonable charge  (no deductible)
Office Visit $10 co-pay then 100% coverage
Hospital Admission $200 co-pay for EACH admission then 100%
Emergency Room $50 co-pay for EACH visit  then 100% ($50 co-pay waived if admitted)
Psychiatric Care Inpatient max 10 days per cal yr subject to a $200 co-pay / outpatient max 20 visits per cal yr subject to a $10 co-pay per visit
Prescriptions $5.00 co-pay for generic - $10 co-pay  for name brand - limited to a 30 day supply - co-pay does not apply to out of pocket max - 
Prescript. NON-network Same for non-network $5 and $10 copay and 100% coverage
Non-Preferred Prov 70% of the U&C amount does not apply to stop loss provision except in an emergency or referred care by a RN
Well care - adult $10 co-pay - for employee & spouse / once every once per calendar year.
Well care - child $10 co-pay - Maximum 6 visits the first yr after birth / 2 visits the 2nd year/ annually from 3-6 years / then once every 12 months
Pap Smear 1 every 12 months for female employees and dependents
PSA 1 every 12 months for male employees that are 50 or older
Cholesterol testing 1 every 12 month period for employee and spouse
Fecal occult blood 1 every 12 month period - for employee and spouse - age 50 and over
Sigmoidoscopy $10 co-pay - 1 every 12 month period for employee and spouse - age 50 and older
Immunizations Childhood immunizations are covered
Maternity / newborn Maternity is for female employee or spouse of a male employee / NOT subject to waiting period provision / circumcision is covered if the mother was eligible for maternity care / Provider & Patient decide on length of stay - post delivery care and follow up care
Spinal manipulation 12 visits per year / $10 co-pay - includes x-rays / out of network 70% NO deductible (per Mark 4-10-00)
Acupuncture 12 visits per year
Massage therapy Must be ordered by a physician - applies to physical therapy limit
Home Health Care Maximum 130 visits per calendar year / 100% / for all conditions combined 
Hospice care Inpatient max 14 days - when Not in an approved hospital you get the same benefits as at home - limited to 6 months
Respite care Min. of 4 or more hours per day - max 120 hours per 3 month period which includes respite and skilled care
Skilled care Min. of 4 or more hours per day - max 120 hours or 6 months which ever is greater (covers: RN, LPN, Home health aide)
Chemical dependency $10,000 every 24 months - NO lifetime max / detox is covered under the emergency room benefit if not enrolled in a program yet
Organ transplant Covered
Organ donor $25,000 max per transplant if donor is covered under this plan 
Rehabilitative treatment (to restore & improve function that was prev normal but lost) Outpatient - 80% max $750 per cal yr/ upon approval up to $2,000 additional per cal yr - NOT subject to stop loss provision 
Inpatient - 80% - subject to stop loss provision - max $1,000 per day to a $10,000 max per condition - EXCEPT if treatment is for cerebral vascular accident, brain injury, or spinal cord injury then $30,000
Neurodevelopmental therapy  $2,000 max per cal year - age 6 a& under - benefits apply to In & Out patient overall max
Urgent Care $10 co-pay 
Ambulance 80% of providers charge - Subject to the stop loss amount
Special Equipment 80% of providers charge - Subject to the stop loss amount (casts, braces, surgical & orthopedic appliances, syringes.
Prostheses 80% no cosmetic prostheses except for external & internal breast prosthesis due to a mastectomy 1 every 3 yrs
Durable medical   equipment 80% of providers charge-Subject to the stop loss amount (rental of beds, wheelchair…) must get approval for purchase - NO benefit for air conditioners, dehumidifiers, purifiers, arch supports, corrective shoes, heating pads, motorized wheelchairs or beds.
Hearing Aids including exams and ear molds 85% to $1,000 every three calendar years
Blood bank charges 80% of providers charge - Subject to the stop loss amount
Dental services   for injury 80% $750 for each separate injury (does not include replacement of filings, repair of deciduous teeth or repair/replacement of bridgework )
Sterilization 80% $1,000 max for surgical sterilization 
PKU 80% for formula necessary for treatment of phenlketonuria - Waiting period provision does not apply 
Diabetic Training 80% to a $150 max per cal yr - $5,000 will be automatically reinstated on January 1st of each year
MAXMIMUM $2,000 per calendar year
Preventative & Diagnostic 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, ORAL HYGIENE INSTRUCTIONS (limited to 3 sessions), PLASTIC SEALANTS (for permanent teeth), SPACE MAINTAINERS
Basic 90%
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
Major 75%
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 implants, bridges, dentures or partials)
TMJ  Maximum $1,000 per calendar year and limited to a combined lifetime of $5,000 as to any one patient.
VISION BENEFITS Covers Eye Exam  with a $10 copay every 24 months - Hardware is covered up to $250 per family per calendar year