|
| PLAN FEATURES |
IN NETWORK |
OUT OF NETWORK |
| Deductible (per calendar year) |
Individual-$250.00 / Family-$750.00 |
Individual-$1,000.00 / Family-$3,000.00 |
| Member Coinsurance |
20% |
40% |
| Payment Limit (per calendar year) |
Individual-$2,750.00 / Family-$8,250.00 |
Individual-$6,000.00 / Family-$18,000.00 |
| Lifetime Maximum |
Unlimited except where otherwise indicated |
Unlimited except where otherwise indicated |
| PREVENTIVE CARE |
|
|
| Routine Adult Physical Exams/Immunizations |
$25 office visit copay |
40% |
| Routine Well Child Exams/Immunizations |
$25 office visit copay |
40% |
| Routine Gynecological Care Exams |
$40 office visit copay |
40% |
| Routine Mammograms For covered females 40 and over |
Covered 100% |
40% |
| Routine Digital Rectal Exam/Prostate-specific Antigen Test For covered males age 40 & over |
Member cost sharing based on type of service and where rendered |
Member cost sharing based on type of service and where rendered |
| Colorectal Cancer Screening For age 50 & over |
Member cost sharing based on type of service and where rendered |
Member cost sharing based on type of service and where rendered |
| Routine Eye Exams (1 routine exam per 24 months) |
$40 office visit copay |
40% |
| PHYSICIAN SERVICES |
|
|
| Office Visits (non surgical) to PCP |
$25 office visit copay |
40% |
| Specialist Office Visits (non-surgical) |
$40 office visit copay |
40% |
| Allergy Testing |
Covered as either a PCP or Specialist Office Visit |
40% |
| Allergy Injections |
Member cost sharing based on type of service/ where rendered |
Member cost sharing based on type of service/ where rendered |
| DIAGNOSTIC PROCEDURES |
|
|
| Diagnostic Laboratory and X-ray |
20% |
40% |
| EMERGENCY MEDICAL CARE |
|
|
| Urgent Care Provider |
20% after $50 co-pay |
40% |
| Non-Urgent Use of Urgent Care Provider |
Not Covered |
Not Covered |
| Emergency Room |
20%; deductible waived |
20%; deductible waived |
| Non-Emergency care in an Emergency Room |
Not Covered |
Not Covered |
| Ambulance |
20% |
40% |
| HOSPITAL CARE |
|
|
| Inpatient Coverage |
20% after $500 per confinement copay |
40% after $1,000 per confinement copay |
| Inpatient Maternity coverage |
20% after $500 per confinement copay |
40% after $1,000 per confinement copay |
| Outpatient Hospital Expenses (including surgery) |
20% |
40% |
| MENTAL HEALTH SERVICE |
|
|
| Inpatient Up to 30 days per calendar year |
20% after $500 per confinement copay |
40% after $1,000 per confinement copay |
| Outpatient Up to 20 visits per calendar year |
$50 copay |
40% |
| ALCOHOL/DRUG ABUSE SERVICES |
|
|
| Inpatient Up to 30 days per calendar year |
20% after $500 per confinement copay |
40% after $1,000 per confinement copay |
| Outpatient Up to 20 days per calendar year |
$50 copay |
40% |
| OTHER SERVICES |
|
|
| Chiropractic |
|
|
| Convalescent Facility Up to 120 days per calendar year |
20% |
40% after $1,000 per confinement copay |
| Home Health Care Limited to 120 visits per calendar year |
Covered 100% |
40% |
| Hospice Care - Inpatient (Limited to 30 days per lifetime) |
20% after $500 per confinement copay |
40% |
| Hospice Care - Outpatient (Maximum benefit of $5,000) |
20% |
40% |
| Private Duty Nursing - Outpatient (Limited to 70- 8 hr shifts) |
20% |
40% |
| Outpatient Short-Term Rehabiitation |
20% |
40% |
| Chiropractic- Limited to 60 visits per calendar year |
|
|
| Durable Medical Equpment |
20% |
40% |
| Diabetic Supplies |
Covered same as any other medical expense |
Covered same as any other medical expense |
| Contraceptive drugs and devices not obtainable at pharmacy (includes coverage for contraceptive visits) |
20% (payable as any other covered expense |
40% (payable as any other covered expense) |
| Transplants |
20% after $500 per confinement copay.In-Network coverage is proved at an IOE contracted facility only |
40% Non-Preferred coverage is provided at a NON-IOE facility |
| Out of Area Employees & Dependents |
Coverage provided at the Out-Of-Network benefit level of the plan |
Coverage provided at the Out-Of-Network benefit level of the plan |
| FAMILY PLANNING |
|
|
| Infertility Treatment |
Member cost sharing is based on type of service performed and place of service rendered |
Member cost sharing is based on type of service performed and place of service rendered |
| Voluntary Sterilization-Incl tubal ligation and vasectomy |
Member cost sharing is based on type of service performed and place of service rendered |
Member cost sharing is based on type of service performed and place of service rendered |
| PHARMACY |
|
|
| Retail |
$15/$25/$40 for a 30 day supply |
Not Covered |
| Mail Order |
$30/$50/$80 31-90 day supply |
Not Covered |
| Prescription drug calendar year deductible |
Individual $100 / Family $300 |
|
This benefit summary is for illustrative purposes only. Please refer to the Summary Plan Description for details. |
