| Plan
Details |
Dental |
| POLICY
# |
PURMS07 |
| EFFECTIVE
DATE |
4/1/2000 |
| MEDICAL |
|
| 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 |
| DENTAL |
|
| DEDUCTIBLE |
$25 for ALL procedures (for
THREE family members) |
| 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 (for persons under 15), 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 |
|
|