| PLAN FEATURES |
IN NETWORK |
OUT OF NETWORK |
| Deductible (per calendar year) |
Individual-$500.00 / Family-$1,500.00 |
Individual-$750.00 / Family-$2,250.00 |
| Member Coinsurance |
20% |
40% |
| Payment Limit (per calendar year) |
Individual-$2,000.00 / Family-$6,000.00 |
Individual-$4,000.00 / Family-$12,000.00 |
| 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 |
$25 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) |
$25 office visit copay |
40% |
| PHYSICIAN SERVICES |
|
|
| Office Visits (non surgical) to PCP |
$25 office visit copay |
40% |
| Specialist Office Visits (non-surgical) |
$35 office visit copay |
40% |
| Allergy Testing |
Member cost sharing based on type of service and where rendered |
40% |
| Allergy Injections |
20% |
40% |
| DIAGNOSTIC PROCEDURES |
|
|
| Diagnostic Laboratory and X-ray |
20% |
40% |
| EMERGENCY MEDICAL CARE |
|
|
| Urgent Care Provider |
20% |
40% |
| Non-Urgent Use of Urgent Care Provider |
Not Covered |
Not Covered |
| Emergency Room |
20%; deductible waived |
10%; deductible waived |
| Non-Emergency care in an Emergency Room |
50% |
50% |
| Ambulance |
20% |
40% |
| HOSPITAL CARE |
|
|
| Inpatient Coverage |
20% after $250 per confinement Copay |
40% after $500 per confinement Copay |
| Inpatient Maternity coverage |
20% after $250 per confinement Copay |
40% after $500 per confinement Copay |
| Outpatient Hospital Expenses (including surgery) |
20% |
40% |
| MENTAL HEALTH SERVICE |
|
|
| Inpatient Up to 30 days per calendar year |
20% after $250 per confinement Copay |
40% after $500 per confinement Copay |
| Outpatient Up to 20 visits per calendar year |
$25 Copay |
40% |
| ALCOHOL/DRUG ABUSE SERVICES |
|
|
| Inpatient Up to 30 days per calendar year |
20% after $250 per confinement Copay |
40% after $500 per confinement Copay |
| Outpatient/Treatment Facility Limited to 20 visitis per calendar year |
$25 Copay |
40% |
| OTHER SERVICES |
|
|
| Convalescent Facility Up to 120 days per calendar year |
20% |
40% |
| Home Health Care Limited to 120 visits per calendar year |
20% |
40% |
| Hospice Care - Inpatient (Limited to 30 days per lifetime) |
20% |
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 |
20% |
40% |
| 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% In-Network coverage is proved at an IOE contracted facility only |
40% Non-Preferred coverage is provided at Non-IOE facility |
| 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 |
$10/$25/$50 for a 30 day supply |
$10/$20/$35 plus 30% of submitted costs for a 30 day supply |
| Mail Order |
$20/$50/$100 31-90 day supply |
Not Covered |
| Prescription drug calendar year deductible |
None |
None |
