| Service |
Network |
Non-Network |
| Hospital |
| Emergency Treatment |
$50 copay
Waived if admitted
100% covered |
$50 copay
Waived if admitted
80% after deductible |
| Inpatient |
Semi-private only
100% covered |
Semi-private only,
80% after deductible |
| Inpatient Ancillary |
100% covered |
80% after deductible |
| Outpatient Services |
100% covered |
80% after deductible |
| Physician Services |
| Surgery |
100% covered |
80% after deductible |
| Inpatient visit |
100% covered |
80% after deductible |
| Office/clinic visit |
$10 Copay
then 100% covered |
80% after deductible |
| Preventive Care |
|
Including immunizations;
outpatient well baby care;
and periodic health exams
|
$750 each year per covered dependent child through end of calendar year in which child attains age one;
$500 maximum per covered person per calendar year.
Not subject to deductible or coinsurance.
|
| Payment Limits per Calendar Year |
Extended Care or
Rehabilitation Center
(combined benefit) 120 days |
100% covered |
80% after deductible |
Therapeutic Manipulation
30 visits |
100% covered |
80% after deductible |
Speech and Cognitive Therapy
(combined benefit) 30 visits |
100% covered |
80% after deductible |
Physical or Occupational Therapy
(combined benefit) 30 visits |
100% covered |
80% after deductible |
| Service |
Network |
Non-Network |
| Mental and Nervous, and Substance Abuse |
| Inpatient 30 Day Max Benefit |
100% covered |
80% after deductible |
| Outpatient 20 Visit Max Benefit |
100% covered |
80% after deductible |
| Other services |
| Anesthesia |
100% covered |
80% after deductible |
| Ambulance |
100% covered |
80% after deductible |
| Durable medical equipment |
100% covered |
80% after deductible |
| Home Care |
100% covered |
80% after deductible |
| Hospice Care |
100% covered |
80% after deductible |
| Lab and X-ray |
100% covered |
80% after deductible |
| Physical Therapy |
100% covered |
80% after deductible |
| Private Duty Nursing |
100% covered |
80% after deductible |
NETWORK Coverage is for "approved care and treatment", i.e., covered services provided by a Network
Provider, and covered inpatient hospital services ordered by a Network Provider while patient is confined in a Network
Hospital.
NON-NETWORK Coverage is based on reasonable and customary charges for covered services as defined in
the Group Plan.
EMERGENCY TREATMENT - means care provided in a hospital, for an injury or a condition that
requires immediate care or treatment, and within 48 hours after the injury is sustained or that condition first becomes
manifest. "Condition that requires immediate care or treatment" means only a permanent health threatening or disabling
condition. "Emergency Treatment" includes ambulance service to the hospital where the treatment is received. Emergency
Treatment Copay is waived if patient is admitted.
DEDUCTIBLE OPTIONS - $250, $500, $1,000 per person, two times for Family deductible. Maximum annual
stop-loss after the deductible: applicable coinsurance limit to $5,000 of eligible expenses, 100% thereafter.
Outpatient hospital ancillary services rendered in connection with scheduled outpatient surgical procedure are covered
as if incurred during confinement. Outpatient copay is waived if patient is admitted.
Amount paid because of deductible and coinsurance for outpatient psychiatric services does not count toward the
out-of-pocket limit when the service is other than "approved care and treatment."
Hospital Precertification and Utilization Review is required for all hospital admissions. Failure to comply will
result in a $500 reduction of covered charges. The amount of the $500 reduction is the patient's responsibility. It
does not count towards the deductible nor the out-of-pocket limit.
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