| PLAN FEATURES |
| Deductible (per calendar year) |
Individual-$500.00 / Family-$1,500.00 |
| Member Coinsurance |
20% |
| Payment Limit (per calendar year) |
Individual-$4,000.00 / Family-$12,000.00 |
| Lifetime Maximum |
Unlimited except where otherwise indicated |
| PREVENTIVE CARE |
|
| Routine Adult Physical Exams/Immunizations |
Not Covered |
| Routine Well Child Exams/Immunizations |
Covered 100% |
| Routine Gynecological Care Exams |
Not Covered |
| Routine Mammograms For covered females 40 and over |
Covered 100% |
| Routine Digital Rectal Exam/Prostate-specific Antigen Test For covered males age 40 & over |
Not Covered |
| Colorectal Cancer Screening For age 50 & over |
Not Covered |
| Routine Eye Exams (1 routine exam per 24 months) |
Not Covered |
| PHYSICIAN SERVICES |
|
| Office Visits (non surgical) to PCP |
20% |
| Specialist Office Visits (non-surgical) |
20% |
| Allergy Testing |
20% |
| Allergy Injections |
20% |
| DIAGNOSTIC PROCEDURES |
|
| Diagnostic Laboratory and X-ray |
20% |
| EMERGENCY MEDICAL CARE |
|
| Urgent Care Provider |
Not Covered |
| Non-Urgent Use of Urgent Care Provider |
Not Covered |
| Emergency Room |
20% |
| Non-Emergency care in an Emergency Room |
50% |
| Ambulance |
20% |
| HOSPITAL CARE |
|
| Inpatient Coverage |
20% after $500 per confinement copay |
| Inpatient Maternity coverage |
20% after $500 per confinement copay |
| Outpatient Hospital Expenses (including surgery) |
20% |
| MENTAL HEALTH SERVICE |
|
| Inpatient Up to 30 days per calendar year |
20% after $500 per confinement copay |
| Outpatient Up to 20 visits per calendar year |
50% (up to 30 days) |
| ALCOHOL/DRUG ABUSE SERVICES |
|
| Inpatient Up to 30 days per calendar year |
20% after $500 per confinement copay |
| Outpatient/Treatment Facility |
50% up to a maximum of $3,557.00 per calendar year |
| OTHER SERVICES |
|
| Convalescent Facility Up to 120 days per calendar year |
20% (limited to 60 days) |
| Home Health Care Limited to 120 visits per calendar year |
20% |
| Hospice Care - Inpatient (Limited to 30 days per lifetime) |
20% |
| Hospice Care - Outpatient (Maximum benefit of $5,000) |
20% |
| Private Duty Nursing - Outpatient (Limited to 70- 8 hr shifts) |
20% |
| Outpatient Short-Term Rehabiitation |
20% |
| Durable Medical Equpment |
20% |
| Diabetic Supplies |
Covered same as any other medical expense |
| Contraceptive drugs and devices not obtainable at pharmacy (includes coverage for contraceptive visits) |
20% |
| Transplants |
20% |
| FAMILY PLANNING |
|
| Infertility Treatment |
Member Cost sharing is based on the type of service and the place where service is rendered. |
| Comprehensive Infertility Services |
Not Covered |
| Advanced Reproductive Technology |
Not Covered |
| Voluntary Sterilization-Incl tubal ligation and vasectomy |
Member Cost sharing is based on the type of service and the place where service is rendered. |
| PHARMACY |
|
| Retail |
$10/$30/$50 for a 30 day supply |
| Mail Order |
$20/$60/$100 31-90 day supply |
| Prescription drug calendar year deductible |
None |
