PURMS

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Plan Details Dental
POLICY #  PURMS04
EFFECTIVE DATE 1/1/2001
MEDICAL  
Service NETWORK NON-NETWORK
Deductible None 200 per person / 600 per family
Doctor $10 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 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 $5.00 co-pay for generic - $10 co-pay  for name brand - $10 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 50%  
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 $2,000.00