|
Inpatient Benefits |
Paid at |
Maximum |
|
Room & Board |
100% |
$750 per day |
ICU/CCU |
100% |
$1,500 per day |
|
Inpatient Physician/Ancillary Services |
75% |
$10,000 per occurrence per policy year |
|
& Surgical Rooms*
Inpatient Surgeon |
75% |
$2,500 per surgery |
|
Inpatient Assistant
Surgeon |
75% |
20% of amount paid to surgeon |
|
Inpatient Anesthesia |
75% |
30% of amount paid to surgeon |
| Maternity
|
same as any sickness |
|
|
Outpatient Benefits |
Paid at |
Maximum |
|
Physician's Office Visit |
100% |
|
|
Per Visit Copay |
|
$25
PCP/$50 Specialists |
|
Number of Visits Per Year |
|
3
for adults/5 for dependent children |
|
Diagnostic, Lab, X-Ray in Office Visit |
100% |
|
|
Wellness Visit: Adult/Child' |
100% |
$100
per policy year |
|
Number of Visits Per Year |
|
1
for adults/1 for dependent children |
| Diagnostic, X-Ray, Lab Facility |
75% |
$25
per visit deductible
$500
per facility per date of service |
| Occupational, Physical, & Speech Therapy |
75% |
$50
per visit deductible
$100
per facility per date of service |
| Durable Medical Equipment |
75% |
$50
per visit deductible
$1,500
per policy year |
|
All Other Outpatient Covered Expenses, |
75% |
$500
per policy year |
|
Emergency Room, |
75% |
$1,500
per facility per date of service |
| Urgent Care Facilityt |
75% |
$250
per visit deductible
$1,500
per facility per date of service |
| Ambulance |
75% |
$150
per visit deductible
$250
per trip |
|
Outpatient Surgical Facility |
75% |
$5,000
per surgery |
|
Outpatient Surgeon |
75% |
$2,500
per surgery |
|
Outpatient Assistant Surgeon |
75% |
20%
of amount paid to surgeon |
|
Outpatient Anesthesia |
75% |
30%
of amount paid to surgeon |
|
Outpatient Chemo/Radiation |
75% |
$1,500
per facility per date of service |
| Outpatient Accident Coverage, |
100% |
$100
per visit deductible
$1,000
per accident |
| Employee Assistance Program/NurseLine |
N/A |
$100
per visit deductible
Unlimited
over-the-phone counseling and up to 3 face-to-face
appointments |
| Ancillary Benefits |
Paid at |
Maximum |
|
|
Prescription Drug'
Generic - $15 Copay (Pharmacy) |
100% |
$1,000
after $50 deductible per policy year
30
day supply |
|
|
$30 Copay (Mail Service) |
100% |
90
day supply |
|
|
Formulary |
50% |
|
|
|
Non-formulary |
25% |
|
