BENEFITS |
NETWORK |
NON NETWORK |
Lifetime Maximum Benefit |
$5,000,000 |
Coinsurance Limit
(excludes copays & deductibles) |
$5,000 |
$10,000
|
Calendar Year Deductible |
$750 Individual
$2,250 Family
|
$1,000 Individual
$3,000 Family |
Coinsurance |
80% |
50% |
Doctor's Office Visit |
Primary Care Physician |
$15 copay |
50% after deductible |
Specialty Care Physician |
$30 copay |
50% after deductible |
Outpatient Therapy |
Physical, occupational, speech or hearing |
$30 copay |
50% after deductible |
Chiropractic Care -
up to $1500 per year |
$30 copay |
50% after deductible |
Preventive Care
including routine exams on an age and gender appropriate basis |
$15 copay |
Not Covered |
Diagnostic X-Ray and Lab Tests
(in free standing facility) |
80% after deductible |
50% after deductible |
Emergency Care (waived if admitted) |
Emergency Room Visits |
$75 copay |
$500 per confinement copay, then 50% |
Other Urgent Care Facilities |
$30 copay |
50% after deductible |
Emergency Ambulance Services: |
Local |
80% after deductible |
80% of PPO schedule, after deductible |
Air Ambulance
up to $18,000 per period of confinement |
80% after deductible |
80% of PPO schedule, after deductible |
Inpatient Facility Services |
Hospital Facility OR Convolescent Care Facility -
50% of semi-private room rate up to 90 days per confinement period |
80% after deductible |
$500 per confinement deductible, then 50% |
Physician Visits |
80% after deductible |
50% after deductible |
Hospital Based Anesthesia, Pathology, Radiology
(payable at network coinsurance if performed ata network facility) |
80% after deductible |
50% after deductible |
Physician's Surgical Services |
Office |
80% after deductible |
50% after deductible |
Hospital (inpatient) |
80% after deductible |
50% after deductible |
Free standing surgical center |
80% after deductible |
50% after deductible |
Outpatient Facility Services
including birthing center, free standing facility |
80% after deductible |
50% after deductible |
Private Duty Nursing -
up to $125 per day |
80% after deductible |
50% after deductible |
Podiatric Services
up to a $2,000 maximum benefit/year |
80% after deductible |
50% after deductible |
Other Health Care |
Durable Medical Equipment
up to a $10,000 lifetime benefit |
80% after deductible |
50% after deductible |
Prosthetic Medical Appliances |
80% after deductible |
50% after deductible |
Home Health Care -
home health aide up to 20 hours per week |
80% after deductible |
50% after deductible |
Hospice Care |
100% after deductible |
50% after deductible |
Hospice Lifetime Maximum |
$10,000 |
Bereavement Counseling
up to $200 per family |
100% after deductible |
50% after deductible |
Prescription Drugs: |
Cal Year Deductible |
None |
Drug Card (30 day supply)
Generic/Brand Name |
$5/$20/$35 |
Mail Service (90 day supply= 1 copay)
Generic/Brand Name |
$5/$20/$35 |
