| PLAN FEATURES |
IN NETWORK |
OUT OF NETWORK |
| Deductible (per calendar year) |
Individual-$4,000.00 / Family-$8,000.00 |
Individual-$4,500.00 / Family-$9,000.00 |
| Member Coinsurance |
30% |
50% |
| Payment Limit (per calendar year) |
Individual-$5,000.00 / Family-$10,000.00 |
Individual-$6,250.00 / Family-$12,500.00 |
| Lifetime Maximum |
Unlimited except where otherwise indicated |
$2,000,000.00 |
| PREVENTIVE CARE |
|
|
| Routine Adult Physical Exams/Immunizations |
100%, not subject to deductible |
50% |
| Routine Well Child Exams/Immunizations |
100%, not subject to deductible |
50% |
| Routine Gynecological Care Exams |
100%, not subject to deductible |
50% |
| Routine Mammograms For covered females 40 and over |
100%, not subject to deductible |
50% |
| Routine Digital Rectal Exam/Prostate-specific Antigen Test For covered males age 40 & over |
100%, not subject to deductible |
50% |
| Colorectal Cancer Screening For age 50 & over |
100%, not subject to deductible |
50% |
| Routine Eye Exams (1 routine exam per 24 months) |
100%, not subject to deductible |
Not Covered |
| PHYSICIAN SERVICES |
|
|
| Office Visits (non surgical) to PCP |
30% |
50% |
| Specialist Office Visits (non-surgical) |
30% |
50% |
| Allergy Testing |
Member cost sharing is based on type of service performed and the place where it is rendered |
50% |
| Allergy Injections |
30% |
50% |
| DIAGNOSTIC PROCEDURES |
|
|
| Diagnostic Laboratory and X-ray |
30% |
50% |
| EMERGENCY MEDICAL CARE |
|
|
| Urgent Care Provider |
30% |
50% |
| Non-Urgent Use of Urgent Care Provider |
Not Covered |
Not Covered |
| Emergency Room |
30% |
30% |
| Non-Emergency care in an Emergency Room |
50% |
50% |
| Ambulance |
30% |
50% |
| HOSPITAL CARE |
|
|
| Inpatient Coverage |
30% |
50% |
| Inpatient Maternity coverage |
30% |
50% |
| Outpatient Hospital Expenses (including surgery) |
30% |
50% |
| MENTAL HEALTH SERVICE |
|
|
| Inpatient Up to 30 days per calendar year |
30% |
50% |
| Outpatient Up to 20 visits per calendar year |
30% |
50% |
| ALCOHOL/DRUG ABUSE SERVICES |
|
|
| Inpatient Up to 30 days per calendar year |
30% |
50% |
| Outpatient Up to $3,500 per calender year |
30% |
50% |
| OTHER SERVICES |
|
|
| Convalescent Facility Up to 120 days per calendar year |
30% |
50% |
| Home Health Care Limited to 120 visits per calendar year |
30% |
50% |
| Hospice Care - Inpatient (Limited to 30 days per lifetime) |
30% |
50% |
| Hospice Care - Outpatient (Maximum benefit of $5,000) |
30% |
50% |
| Private Duty Nursing - Outpatient (Limited to 70- 8 hr shifts) |
30% |
50% |
| Outpatient Short-Term Rehabiitation |
30% |
50% |
| Chiropractic- |
30% |
50% |
| Durable Medical Equpment |
30% |
50% |
| Diabetic Supplies |
30% |
50% |
| Contraceptive drugs and devices not obtainable at pharmacy (includes coverage for contraceptive visits) |
30% |
50% |
| Transplants |
30% if performed at an IOE contracted facility only |
50% |
| 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 the place where it is rendered |
Member cost sharing is based on type of service performed and the place where it is rendered |
| Voluntary Sterilization-Incl tubal ligation and vasectomy |
Member cost sharing is based on type of service performed and the place where it is rendered |
Member cost sharing is based on type of service performed and the place where it is rendered |
| PHARMACY |
|
|
| Retail |
$15/$25/$40 after plan deductible met the co-pays will apply |
50% after plan deductible and applicable co-pays |
| Mail Order |
$30/$50/$80 after plan deductible met the co-pays will apply |
Not Covered |
