PURMS

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Plan Detail Dental
POLICY #  PURMS06
EFFECTIVE DATE 5/1/2003
  Network Non Network
     
Max Cal. Yr. Out of Pocket $1,250 per person $2,500 per person 
  $2,500 per Family $5,000 per Family 
Lifetime Max per Person Unlimited    Unlimited
Outpatient Services                      
Physicians office-home visits $10 Copay per visit per person paid to the Physician's office at time of visit for all services provided on same day 30% coinsurance 
Services of a Chiropractor $10 Copay per visit per person limited to 6 visits per year unless certified as necessary by a physician. 30% coinsurance limited to 6 visits per year unless certified as necessary by a physician.
Birth control devices (IUD & depo-provera) $10 Copay 30% coinsurance
Ultrasound / EKG / X-ray/and similar diagnostic services No Charge 30% coinsurance 
Preventive care $10 Copay per visit 30% coinsurance
Antigen Admin. Including serum $3 per injection 30% coinsurance
Hospital Outpatient Services - SURGERY & Procedures  $50 Copay per surgery  30% coinsurance 
Hospital Outpatient Services - Emergency room $20 Copay per admission $50 Copay per admission
  Waived if admitted  Waived if admitted 
Outpatient Alcohol/drug treatment - Limited to $5,000 per 24 month period combined inpatient and outpatient - $10,000 lifetime limit,  Inpatient / outpatient combined $10 Copay per visit 30% coinsurance 
Outpatient rehabilitation services - Physical, speech, occupational and respiratory therapy combined (limit 60 visits per cal. Year) $10 Copay per visit 30% coinsurance 
Neurodevelopment therapy for children - 6 & under limited to a maximum of $2,500 per cal yr per person $10 Copay per visit 30% coinsurance 
Outpatient cardiac rehab.  Services - limited to 36 visits cal yr $10 Copay per visit 30% coinsurance 
Mental health care - limited to 20 visits per cal yr. MUST call mental health provider for authorization prior to visit for mental health, alcoholism, and drug abuse $10 Copay per visit 50% coinsurance 
Inpatient Services -  $250 Copay per admission per person $250 Copay per admission per person
Semi-Private room Private room (if medically necessary) 100% after Copay 30% coinsurance
Intensive and coronary care unit (if medically necessary) 100% after Copay 30% coinsurance
Physician & surgeon services, anesthesia, nursing care, & related services 100% after Copay 30% coinsurance 
Mental health care - limited to 10 day per cal yr. 100% after Copay 50% coinsurance 
Inpatient alcohol & drug treatment (limited to $5,000 in a 24-month period for combined inpatient & outpatient services - Limit $10,000 lifetime max,  Inpatient / outpatient combined 100% after Copay 30% coinsurance
Other Services    
Ambulance - ground  100% if emergent, 50% if not 100% if emergent, 50% if not
Ambulance - air  100% if emergent, 50% if not 100% if emergent, 50% if not 
Medical care at urgent care facility $20 Copay per visit 30% coinsurance 
Diabetic Rehab & risk services and supplies 20% coinsurance  30% coinsurance 
Ostomy supplies 20% coinsurance 30% coinsurance 
Durable medical equipment & external prostheses -limit $5,000 per cal yr 20% coinsurance 50% coinsurance 
Organ & tissue transplants - see comprehensive medical benefit section of this booklet for specific coverage $1,000,000 lifetime max benefit Applicable co-payment - see inpatient & outpatient services 50% coinsurance 
Skilled nursing facility services - limited to 90 days per cal year $10 Copay per day up to a maximum of $250. 30% coinsurance 
Home Health care services - limited to 60 visits per cal year $10 Copay per day up to a maximum of $250. 30% coinsurance 
Hospice care services - limited to 180 days per lifetime $10 Copay per day up to a maximum of $250. 30% coinsurance 
Hearing Aids are covered at $100 / 3 years  $100 / 3 years
Vision benefits    
One refraction during per calendar year $10 per refraction $10 per refraction
Hardware  
Any two year period $300 $300
Limitations and exclusions: non-prescription glasses, prescription and non-prescription sunglasses when not medically necessary, and services on products not specifically listed above.  Other provisions, limitations and exclusions of the insured's booklet of insurance may also apply.      
Prescription drug benefit - must use a participating pharmacy    
Generic prescription $6 Copay $6 Copay
Brand name (when no generic is available) $10 Copay $10 Copay
Brand name (when generic is available) $15 Copay $15 Copay
Mail order prescription - generic drug $10 Copay for up to a 90 day supply  $10 Copay
Mail order prescription - name brand / when no generic is available $15 Copay for up to a 90 day supply  $15 Copay
Mail order prescription - name brand / when generic is available $20 Copay for up to a 90 day supply $20 Copay
Mail order prescription - name brand / when generic is available You pay the difference between the generic and name brand drug in addition to the brand name copay amount reimbursement (minus deductible amount & unallowable costs) will be made for eligible charges for prescriptions filled by a non-participating, out-of area pharmacy for emergency care or urgent care via submission of the prescription bill with a completed claim form for direct reimbursement.
Emergencies & urgent care - To be eligible - medications must be dispensed in accordance with the Drug formulary which is provided to your doctor and pharmacy. Some medications require prior authorization.  Medications may only be dispensed by written prescription of a duly licensed health care provider    
DENTAL    
DEDUCTIBLE  $50 FOR BASIC AND/OR MAJOR
PRE-DETERMINATION REQUIRED NO - BUT RECOMMENDED
MAXIMUM PAYABLE $1,500 PER PERSON / PER CAL. YEAR
PREVENTIVE  
INCLUDES EXAMS - PROPHY - FLUORIDE - X-RAYS - SEALANTS - SPACE MAINTAINERS - STUDY MODELS/DIAGNOSTIC CASTS*
DEDUCTIBLE  NONE
ORAL EXAMS 80% NOT MORE THAN ONCE EVERY 6 MONTHS
FULL MOUTH X-RAY FREQUENCY 80% NOT MORE THAN ONCE EVERY 3 YRS
BITEWINGS FREQUENCY 80% NOT MORE THAN ONCE EVERY 6 MONTHS
PROHPY FREQUENCY 80% NOT MORE THAN ONCE EVERY 6 MONTHS
FLUORIDE FREQUENCY 80% ONCE PER YEAR
FLUORIDE TO AGE 19
SEALANTS COVERED ON PERMANENT MOLARS
SEALANTS TO AGE AGES 6 TO UNDER AGE 19
BASIC/RESTORATIVE  
INCLUDES FILLINGS - ENDODONTICS - PERIODONTICS - DENTURE REPAIRS - ORAL SURGERY - OFFICE VISITS - APPLIANCE TO CORRECT THUMBSUCKING - EMERG. PALLIATIVE TREATMENT - SPEC. CONSULT. 
PERIO - HOW IS IT COVERED? 80% SCALING NOT MORE THAN ONCE EVERY 6 MONTHS
BASIC RESTORATIVE PERCENTAGE 80%
BASIC RESTORATIVE DEDUCTIBLE $50.00
BITEGUARD COVERAGE YES - $50 DEDUCTIBLE 80%
MAJOR   
INCLUDES CROWNS - BRIDGES - PONTICS - DENTURES
MAJOR  PERCENTAGE 50%
DEDUCTIBLE  $50
RESTRICTIONS MUST BE 5 YEARS SINCE LAST PLACEMENT  
ORTHODONTICS NO DEDUCTIBLE / 50% / TO A LIFETIME MAXIMUM PAYABLE OF $1,500
LIMITATIONS/WAITING PERIODS YES - IF ELIGIBLE FOR COVERAGE AND YOU DON'T ENROLL 
MISSING TOOTH CLAUSE? NO