Benefit Description

In Network Benefits

Out of Network Benefits

Calendar Year Deductible
per person

$0

$ 500

Coinsurance

80% 

75%

Out of pocket max.. Per individual

 $ 2,000

$ 7,000

Out of pocket max.. Per family

$ 10,000

Benefit Description

In Network Benefits

Out of Network Benefits

Professional Services

Surgery, anesthesia, radiation therapy, in hospital doctor visits, diagnostic X-ray and Lab.

80%

75%

Office visits - including X-rays and lab work billed by the attending physician on the same date of service.

$20 Copayment

75%

Preventive Care

Babies/Children through age 6:

 -- Office visit /examination related to preventive care including lab work billed by the attending physician on the same date of service.

$20 Copayment

70%

- immunizations and lab work not billed with the office visit by the attending physician on the same date of service

100%

100%

Adults

• Office visit/examination related to services for Routine Pap smears, annual mammograms, and PSA for men.
• Routine Pap smears, annual mammograms, and PSA for men

$20 Copay

80%

75%

75%

Outpatient Medical Care

80%

75%

Physical/Occupational Therapy/Medicine

As much as $25 per visit and as many as 12 visits per year. Additional visits may also be available through the Home Health benefit if approved by Managed Care Services.

Acupuncture/ Accupressure

As much as $25 per visit and as many as 12 visits per year.

Mental, Emotional or Functional Nervous disorders & Counseling treatment for Alcoholism

• Inpatient: $100 per day up to $3,000 per year. ( Exception: inpatient treatment of alcoholism is payable as any other medical condition)
• Outpatient: As much as $25 per visit and as many as 20 visits per year.

Smoking Cessation

Up to $50 for drugs and $50 per insured person for any cessation program per lifetime.

Infusion Therapy

Administration of drugs and other substances in ways other than oral: such as chemotherapy through a vein.

80%

75%

Durable Medical Equipment

80%

75%

Inpatient Hospital Services

80%

75%

- A surgery, x-rays, election of non-emergency services, organ/tissue transplant.

80%

75% - less an additional $500 penalty.

- Medical emergency Pre-certification required on all plans.

80%

80% until transferable to a participating hospital, then 70%

Ambulatory Surgical Center

80%

75%

Ambulance ( must be necessary) - Max benefit up to $750 per trip.

80%

75%

Home Health Care - of covered expenses to 60 visits per year.

80%

75%

Skilled Nursing Facility - Max. covered expenses $400 per day, 100 days per year.

80%

75%

Hospice - $10,000 lifetime maximum

80%

75%

Prescription Drug Card.

• Generic Drugs
• Brand Name Drugs

At preferred Pharmacies

• $10 copayment
• $20 copayment