| 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 |
$2,000,000 |
| 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 |
|
|
|