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Fee-For-Service
Self Funded Plan
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PPO Provider
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Non-PPO Provicer
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Medical Procedure
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All benefits are payable based on the allowable charges as defined in the Summary Plan Description.
Pre-authorization is recommended for all benefits indicated with an asterisk (*)
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PPO Provider
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Non-PPO Provider
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| Annual Deductible |
$300 per person; maximum of three deductibles per family (subject to change) Deductible applices to most services |
$600 per person; maximum of three deductibles per family (subject to change) Deductible applies to most services |
| Annual Co-Payment Limit on Allowable Charges |
Plan pays 100% of allowable charges after $10,000 in a year per person |
Plan pays 80% of allowable charges after $10,000 in a year per person |
| Overall Lifetime Maximum |
$1,000,000 per person (incremental after $750,000)
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| Hospital - |
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Inpatient
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*Plan pays 75%
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*Plan pays 60%
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*Plan pays 75%
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*Plan pays 60%
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| Extended Care Facility (Skilled Nursing) |
Plan pays 75%; 60 days maximum |
Plan pays 60%; 60 days maximum |
| Physician Services |
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Office Visits
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Plan pays 75% |
Plan pays 60% |
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Plan pays $400 per exam per year, including all tests |
Plan pays $400 per exam per year, including all tests |
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Plan pays 100% per exam, including tests; 16 exams maximum |
Plan pays $40 per exam, including tests; 16 exams maximum |
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Plan pays 100% per exam, including tests; once every 2 years |
Plan pays $40 per exam, including tests; once every 2 years |
Inpatient Surgery
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Plan pays 75% |
Plan pays 60% |
Outpatient Surgery
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Plan pays 75% |
Plan pays 60% |
Hospital Visits
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Plan pays 75% |
Plan pays 60% |
| Diagnostic X-Ray and Lab |
Plan pays 75% |
Plan pays 60% |
| CAT Scans & MRI's |
*Plan pays 75%
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*Plan pays 60%
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| Durable Medical Equipment |
*Plan pays 75%
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*Plan pays 60%
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| Casts, Splints, Trusses, Braces & Crutches |
Plan pays 75% |
Plan pays 60% |
| Home Nursing Care |
* Plan pays 75%; $1,000 maximum per year, $4,000 lifetime maximum |
* Plan pays 60%; $1,000 maximum per year, $4,000 lifetime maximum |
| Chiropractic Care |
Plan pays up to $20 per visit; $400 maximum per year
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| Physical Therapy |
* Plan pays 75%; limit of 32 visits within 6 consecutive months |
* Plan pays 60%; limit of 32 visits within 6 consecutive months |
| Speech Therapy |
Not covered
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| Maternity Care |
Same as any other illness except birthing center paid at 100% up to $1,500 with no deductible, and certified nurse-midwife paid at 100% up to $750 with no deductible |
| Psychiatric Care - |
Pre-authorization Recommended
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* Plan pays 50% of all cover services up to a maximum of 31 days per calendar year |
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* Plan pays 50% of all cover services up to a maximum of 40 days per calendar year |
| Substance Abuse - |
Must be Preauthorized and arranged by the Beat-It! Program at (800)-828-3939 |
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Plan pays maximum of $500 per day and $12,500 per calendar year, limited to two confinements per lifetime (subject to a lifetime maximum of $30,000) No benefits if not pre-authorized |
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Plan pays maximum of $55 per visit; $2,200 maximum per year, (subject to lifetime maximum of $30,000) No benefits if not pre-authorized |
| Prescription Drugs |
Must be obtained at an ExpressScripts Network pharmacy |
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You pay $10 per generic, $20 per brand name, and $35 per non-preferred prescription. Preferred formulary lists available upon request. |
Maintenance (30 day supply or more)
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ExpressScripts Mail Order Pharmacy -
You pay $15 per generic, $30 per brand name, and $50 per non-preferred prescription for a 90-day supply. Preferred formulary lists available upon request.
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| Hearing Aids |
Not covered
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| Emergency Room Care |
You pay $50 co-pay per Emergency Room visit, plus the balance due after the remaining expenses have been processed according to the regular Plan benefits, subject to the calendar year deductible and co-insurance percentages. The $50 co-pay is waived if admitted to the hospital. PPO benefits will be paid only if the condition fits the following definition: "An emergency is a sudden, serious and unexpected illness, injury or condition requiring immediate medical attention. The provider must certify that it is an emergency." Routine illnesses or minor injuries are not considered emergencies and will be paid at no-PPO benefits. |
