| Plan
Details |
Dental |
|
| POLICY
# |
PURMS14 |
|
| EFFECTIVE
DATE |
12/1/2004 |
|
| MEDICAL |
|
|
| Service |
NETWORK |
NON-NETWORK |
| Deductible |
None |
300 per person / 900 per
family |
| Doctor |
$15 copay then 100% |
70% after deductible |
| Emergency
Room Visit |
$75 copay then 100% |
70% after deductible |
| Out
of Pocket |
$2,500 per person $7,500
per family, per calendar year |
$10,000 per person $30,000
per family, per calendar year |
| Ambulance
Services |
80% |
80% |
| Ambulatory
Surgical Center |
100% |
70% |
| Chemical
Dependency Treatment Facility Services |
100% |
70% |
| Home
Health and Hospice Care |
100% |
70% |
| Home
Medical Equipment Company |
100% |
70% |
| Home
Phototherapy |
100% |
70% |
| Hospital
Services and Supplies |
100% |
70% |
| Infusion
Therapy max $25,000 per cal. year |
100% |
70% |
| Neurodevelopment
Therapy |
100% |
70% |
| Phenylketonuria
Formulas |
100% |
70% |
| Preventive
Care |
100% |
0% |
| Professional
Services as described in the Benefits section (unless otherwise specified) |
100% |
70% |
| Prostheses
and Orthotics |
100% |
70% |
| Rehabilitative
Services |
100% |
70% |
| Routine
Eye and Hearing Exams |
100% |
$40 maximum |
| Screening
Mammograms |
100% |
70% |
| Skilled
Nursing Facility Services |
100% |
70% |
| Smoking
Cessation |
80% |
80% |
| Transplants |
100% |
See Benefits |
| Psychotherapy |
|
|
| Outpatient
care, Subject to copay |
15 visits |
15 visits |
| Prescriptions |
$10.00 co-pay for generic - $20 co-pay for name brand - $20 mail order name brand
or generic |
| DENTAL |
|
|
| Class
I |
70% through 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 |
| Class
II |
70% through 100% |
|
| 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 |
| Class
III |
Constant 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 bridges, dentures or
partials) |
| Annual
Maximum |
3000 |
|
|
|
|