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Open Access Managed Choice POS Executive Plan
| PLAN FEATURES | IN NETWORK | OUT OF NETWORK |
| Deductible (per calendar year) | None | Individual-$250.00 / Family-$750.00 |
| Member Coinsurance | Covered at 100% | 20% |
| Payment Limit (per calendar year) | None | Individual-$1,000.00 / Family-$2,000.00 |
| Lifetime Maximum | Unlimited except where otherwise indicated | Unlimited except where otherwise indicated |
| PREVENTIVE CARE | ||
| Routine Adult Physical Exams/Immunizations | $10 office visit copay | 20% |
| Routine Well Child Exams/Immunizations | $10 office visit copay | 20% |
| Routine Gynecological Care Exams | $10 office visit copay | 20% |
| Routine Mammograms For covered females 40 and over | Covered 100% | 20% |
| 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) | $10 office visit copay | 20% |
| PHYSICIAN SERVICES | ||
| Office Visits (non surgical) to PCP | $10 office visit copay | 20% |
| Specialist Office Visits (non-surgical) | $10 office visit copay | 20% |
| Allergy Testing | Covered as either a PCP or Specialist Office Visit | Member cost sharing based on type of service/ where rendered |
| 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 | Covered 100% | 20% |
| EMERGENCY MEDICAL CARE | ||
| Urgent Care Provider | $50 Copay | 20% |
| Non-Urgent Use of Urgent Care Provider | Not Covered | Not Covered |
| Emergency Room | $100 Copay | $100 Copay |
| Non-Emergency care in an Emergency Room | Not Covered | Not Covered |
| Ambulance | Covered 100% | 20% |
| HOSPITAL CARE | ||
| Inpatient Coverage | Covered 100% | 20% |
| Inpatient Maternity coverage | Covered 100% | 20% |
| Outpatient Hospital Expenses (including surgery) | Covered 100% | 20% |
| MENTAL HEALTH SERVICE | ||
| Inpatient Up to 30 days per calendar year | Covered 100% | 20% |
| Outpatient Up to 20 visits per calendar year | $10 Copay | 20% |
| ALCOHOL/DRUG ABUSE SERVICES | ||
| Inpatient Up to 30 days per calendar year | Covered 100% | 20% |
| Outpatient Up to 20 days per calendar year | $10 Copay- maximum benefit of $3,500.00 per calendar year | 20% maximum benefit of $3,500.00 per calendar year |
| OTHER SERVICES | ||
| Convalescent Facility Up to 120 days per calendar year | Covered 100% | 20% |
| Home Health Care Limited to 120 visits per calendar year | Covered 100% | 20% |
| Hospice Care - Inpatient (Limited to 30 days per lifetime) | Covered 100% | 20% |
| Hospice Care - Outpatient (Maximum benefit of $5,000) | Covered 100% | 20% |
| Private Duty Nursing - Outpatient (Limited to 70- 8 hr shifts) | Covered 100% | 20% |
| Outpatient Short-Term Rehabiitation | Covered 100% | 20% |
| Chiropractic- Limited to 60 visits per calendar year | Covered 100% | 20% |
| Durable Medical Equpment | Covered 100% | 20% |
| 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) | Covered 100% (payable as any other covered expense | 20% (payable as any other covered expense) |
| Transplants | Covered 100% In-Network coverage is proved at an IOE contracted facility only | 20% 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 |
| Comprehensive Infertility Services | Covered 100% | Not Covered |
| 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 | $10/$20/$35 for a 30 day supply | $15/$25/$40 plus 40% of submitted costs for a 30 day supply |
| Mail Order | $20/$40/$70 31-90 day supply | Not Covered |
| Prescription drug calendar year deductible | None | None |
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