|
Medical Procedure
|
|
|
| Annual Deductible |
None
|
| Annual Co-Payment Limit on Allowable Charges |
Plan pays 100% after co-payments reach $1,500 in a year ($4,500 for a family) |
| Overall Lifetime Maximum |
None
|
| Hospital - |
|
|
|
You pay $400 per admission |
|
|
Plan pays 100% |
| Extended Care Facility (Skilled Nursing) |
You pay $400 per admission; 100 days maximum |
| Physician Services |
|
Office Visits
|
You pay $20 per visit (no charge for maternity & well-baby care) |
|
|
You pay $20 per visit |
|
|
You pay $20 per visit (no charge for well-baby care) |
|
|
You pay $20 per visit |
Inpatient Surgery
|
Plan pays 100% |
Outpatient Surgery
|
Plan pays 100% |
Hospital Visits
|
Plan pays 100% |
| Diagnostic X-Ray and Lab |
Plan pays 100% |
| CAT Scans & MRI's |
Plan pays 100% (pre-authorization required) |
| Durable Medical Equipment |
Plan pays 100% |
| Casts, Splints, Trusses, Braces & Crutches |
Plan pays 100% |
| Home Nursing Care |
Plan pays 100% |
| Chiropractic Care |
Not covered
|
| Physical Therapy |
You pay $20 per visit |
| Speech Therapy |
You pay $20 per visit; maximum of 50 visits or six months of treatment |
| Maternity Care |
Same as any other illness |
| Psychiatric Care - |
|
|
|
You pay $400 per admission; 30 days maximum |
|
|
You pay $20 per visit; 30 visit maximum |
| Substance Abuse - |
You may choose between coverage under the Beat It! Program or your HMO, or a combination of both, as follows (See California Fee-for-Service Plan B for Beat It! details):
|
|
|
Plan pays 100% ($25,000 annual maximum, $35,000 lifetime maximum) |
|
|
Plan pays 100% ($25,000 annual maximum, $35,000 lifetime maximum) |
| Prescription Drugs |
Must be obtained at a participating HMO pharmacy |
|
|
You pay $15 per generic and $35 per brand name prescription |
Maintenance (30 day supply or more thru the Mail Order)
|
Mail order - you pay 2 co-pays per prescription for a 90-day supply |
| Hearing Aids |
Not covered
|
| Emergency Room Care |
You pay $35 (co-payment waived if admitted to hospital) |
