The following Schedule of Benefits is designed as a quick reference. For complete provisions of the Plan’s benefits, refer to the following sections: Health Care Management, Medical Expense Benefit and Plan Exclusions. A complete listing of participating providers can be obtained from the Human Resources Department. Limitations are combined maximums for services and supplies rendered by Preferred and Non-Preferred Providers.
|
Maximum Benefit per Covered Person while covered by this Plan for: |
||
|
|
Medical |
$ 1,000,000 |
|
|
|
|
|
|
|
|
|
|
25,000 |
|
|
Maximum Benefit per Covered Person per Calendar Year for: |
|||
|
|
Mental and Nervous Disorders |
Inpatient/30 days per calendar year |
|
|
|
|
Outpatient/25 visits per calendar year |
|
|
|
Chemical Dependency Inpatient &/or Outpatient Hospital |
|
|
|
|
Inpatient Services |
$ 10,000 |
|
|
|
Chemical Dependency Outpatient Services |
2,000 |
|
|
|
(Included in the Inpatient and/or Outpatient limit of $10,000) |
|
|
|
|
Extended Care Facility/Treatment and Confinement |
30 days per calendar year |
|
|
|
Chiropractic Care |
$ 300 |
|
|
|
Home Health Care |
100 visits per Calendar Year |
|
|
|
Preventive Care |
$ 300 |
|
|
Calendar Year Deductible: |
||
|
|
Individual Deductible |
|
|
|
Family Deductible (Aggregate) |
|
|
|
|
|
Coinsurance Expense Limit Per Calendar Year |
||
|
|
Individual |
|
|
|
|
|
Additional Deductibles
|
|
|
|
|
Hospital Admission NOT Pre-Authorized |
|
|
|
Outpatient Surgery NOT Pre-Authorized * |
|
|
|
*Outpatient Surgeries where the Surgeon’s charges are $401 or more require Pre-Authorization. Refer to the section entitled Health Care Management for more details. |
|
Limitation per Occurrence
|
|
|
|
|
Hospital Inpatient/Outpatient
Surgery Covered Expenses NOT
Pre-Authorized/ |
|
|
|
80% |
|
|
|
80% |
|
|
|
|
|
|
|
Hospital
Inpatient/Outpatient Surgery Covered Expenses NOT Pre-Authorized/ |
|
|
|
60% |
|
|
|
0% |
|
The following are Covered Dental Services. Refer to the section entitled Dental Provisions, Dental Benefits, for details regarding the services covered, exclusions, limitations and other provisions of the Dental Benefit.
|
ALL PROVIDERS |
||
|
CLASS I |
80% |
|
|
|
Limitation: Subject to maximum annual benefit per person |
|
|
CLASS II |
80% |
|
|
|
Limitation: Subject to deductible and maximum annual
benefit per person. |
|
|
CLASS II |
80% |
|
|
|
Limitation: Subject to deductible and maximum annual
benefit per person.) |
|
|
CLASS IV |
50% |
|
|
|
Limitation: Subject to deductible and maximum lifetime benefit per person.) |
|
ALL CLASSES
CLASSES I, II, III
CLASS IV
(To be effective July
1, 1998)
|
ALL PROVIDERS |
||
|
Individual Calendar Year Deductible: |
$25 |
|
|
Examination / Maximum Benefit: |
$40 |
|
|
|
Limitation: One exam during any 18 consecutive months. |
|
|
Conventional Lenses / Maximum Benefit: |
|
|
|
|
Single Vision |
$40 |
|
|
Bi-focal |
$50 |
|
|
Tri-focal |
$60 |
|
|
Lenticular |
$120 |
|
|
|
|
|
|
$200 |
|
|
|
$100 |
|
|
|
Limitation: One pair during any 18 consecutive months. |
|
|
Frames / Maximum Benefit: |
$40 |
|
|
|
Limitation: One pair during any 18 consecutive months. |
|
|
Refer to the section entitled Vision Expense Benefit for complete details. |
|
|
For the purpose of determining the Coinsurance and Out-of-Pocket Expense Limit, Covered Expenses are divided into the following three categories:
CATEGORY 1:
This category applies to such Covered Expenses made by all Preferred Providers. For Employees who reside or work outside the Preferred Provider service area (50 Miles or more from the nearest Preferred Provider), Covered Expenses for Non-Preferred Provider services and supplies shall be Category 1 expenses.
CATEGORY 2:
This category applies to such Covered Expenses made by Providers that are Non-Preferred Providers if:
1. Such expenses are made by pathologists, radiologists, or anesthesiologists in connection with a covered Inpatient Preferred Hospital Confinement or a covered Outpatient procedure performed in a Preferred Hospital.
2. Such expenses are necessitated by an Emergency condition (as defined in the Plan), and then only to the following extent: (a) in the case of Emergency Outpatient treatment, such expenses incurred within twenty-four (24) hours of the accident; and (b) in the case of an Inpatient Hospital Confinement, such expenses up to the day the Covered Person can reasonably be expected to safely transfer to a Preferred Provider.
3. Such expenses are for care, treatment, services, or supplies that are not rendered by any Preferred Provider.
4.
Such
expenses are incurred while traveling outside of the Preferred Provider area
(50 miles or more from the nearest Preferred Provider).
CATEGORY 3:
This category applies to such Covered Expenses made by all other Non-Preferred Providers.
Note: If the Covered Person elects to use Category
3, the Coinsurance payable by the Covered Person shall NOT apply to the
Out-of-Pocket Expense Limit.
Out-of-Pocket Expense Limit Per
Calendar Year:
|
|
Individual |
$ 1,000 |
|
|
Family (Aggregate) |
2,000 |
Refer to the section entitled Medical Expense Benefit, Out-of-Pocket Expense Limit for a listing of charges not applicable to the Out-of-Pocket Expense Limit.
The Plan pays the percentage listed on the following pages for Covered Expenses incurred by a Covered Person during a Calendar Year after the Individual or Family Deductible has been satisfied and until the Individual or Family Out-of-Pocket Expense Limit has been reached. Thereafter, the Plan pays 100% of incurred Covered Expenses for the remainder of the Calendar Year, or until the Maximum Benefit has been reached. Refer to the section entitled Medical Expense Benefit, Out-of-Pocket Expense Limit for a listing of charges not applicable to the 100% Coinsurance.
|
PLAN A Benefit
Description |
PPO Provider Category 1 |
(see Page 7) Category 2 |
Non-PPO Provider Category 3 |
|
|
INPATIENT HOSPITAL |
90%* |
80% |
70%** |
|
|
|
* Benefits
for Inpatient Hospital/Network/Not
Pre-authorized will be subject to a separate
and additional $300 Deductible and 80% Coinsurance payment per unapproved
admission. |
|||
|
|
** Benefits
for Inpatient Hospital/ Non-Network/Not Pre-authorized will be subject to a separate
and additional $300 Deductible and 60% Coinsurance payment per unapproved
admission. |
|||
|
|
|
|
|
|
|
OUTPATIENT SURGERY |
90%* |
80% |
70%** |
|
|
|
* Benefits
for Outpatient Surgery/Network/Not Pre-authorized will be subject to a separate
and additional $300 Deductible and 80% Coinsurance payment per unapproved
surgical procedure. |
|||
|
|
** Benefits
for Outpatient Surgery/Non-Network/Not Pre-authorized will be subject to a separate
and additional $300 Deductible and 60% Coinsurance payment per unapproved
surgical procedure. |
|||
|
|
|
|
||
|
ER SERVICES |
100%
after $100 Co-pay* Deductible Waived |
100% after $100 Co-pay* Deductible Waived |
100%
after $100 Co-pay* Deductible Waived |
|
|
|
*The $100 Co-payment is waived if Covered
Person is admitted to the Hospital; coverage reverts to Hospital Inpatient as
noted above. |
|||
|
|
|
|
||
|
URGENT CARE |
90% Subject to Deductible* |
90% Subject to Deductible* |
90% Subject to Deductible* |
|
|
|
*No Co-payment required. |
|||
|
|
|
|
||
|
SUPPLEMENTAL ACCIDENT |
100% Ded. Waived up to $500.* |
100% Ded. Waived up to $500.* |
100% Ded. Waived up to $500.* |
|
|
|
*Limitation: Maximum Benefit is $500 per accident; coverage then reverts to Plan Benefits. |
|||
|
|
|
|
||
|
PRE-ADMISSION TESTING |
90% |
80% |
70% |
|
|
PHYSICIANS’ SERVICES |
90% |
80% |
70% |
|
|
|
Assistant Surgeon’s Covered Expenses not to exceed 20% of the primary Physician’s Covered Expenses. |
|||
|
|
|
|
||
|
SECOND SURGICAL OPINION |
|
|
|
|
|
100% Ded. Waived |
100% Ded. Waived |
70% Ded. Waived |
||
|
100% Ded. Waived |
100% Ded. Waived |
70% Ded. Waived |
||
|
OUTPATIENT DIAGNOSTIC |
|
|
|
|
|
90% |
80% |
70% |
||
|
|
|
|
||
|
90% |
80% |
70% |
||
|
|
Limitation: Up to 30 days for treatment and Confinement per Calendar Year. |
|||
|
|
|
|
||
|
90% |
80% |
70% |
||
|
|
|
|
||
|
90% |
80% |
70% |
||
|
|
Limitation: Maximum Benefit per family unit for family bereavement counseling
is $200. |
|||
|
|
|
|
||
|
90% |
80% |
70% |
||
|
|
Limitation: Maximum Benefit per Calendar Year not to exceed 100 days
rental; Maximum Benefit per Calendar Year for rental of Apnea Monitor (except
if used for infants), T.E.N.S. Unit, or equipment designed to assist
bones to heal faster is limited to
$200 each. |
|||
|
|
|
|
||
|
100% to $300 Ded. Waived* |
Denied |
Denied |
||
|
|
*Limitation: Up to $300 per Calendar Year benefit. |
|||
|
|
|
|
||
|
90%* |
90%* |
70%* |
||
|
|
*Inpatient services subject to maximum 30 days per calendar year; Outpatient services subject to maximum 25 visits per calendar year. |
|||
|
|
|
|
||
|
|
|
|
||
|
90%* |
90%* |
70%* |
||
|
|
*Limitation: $10,000 per Covered Person, per Calendar Year for Inpatient and
Outpatient Hospital. |
|||
|
|
|
|
||
|
50%* |
50%* |
50%* |
||
|
|
*Limitation: $2,000 per Covered Person, per Calendar Year (included in the Inpatient and/or Outpatient limit of $10,000). |
|||
|
|
|
|
||
|
90% |
80% |
70% |
||
|
|
|
|
||
|
90% |
80% |
70% |
||
|
|
|
|
||
|
N/A |
100%* |
N/A |
||
|
|
*Maximum Benefit: $25 per treatment; maximum of 26 treatments per Calendar
Year. |
|||
|
|
|
|
||
|
N/A |
80% |
N/A |
||
|
|
|
|
||
|
N/A |
90% Ded. Waived |
N/A |
||
|
|
|
|
||
|
90% |
80% |
70% |
||
|
|
|
|
||
|
N/A* |
N/A* |
N/A* |
||
|
|
*100% after Prescription Drug
Co-payment: $5 generic/$15 brand
name. Generic will be dispensed unless specified “Dispense as Written.”
Maintenance drugs will be dispensed through a mail order program. |
|||
|
|
|
|
||
For the Purpose of determining the Coinsurance and Out-of-Pocket Expense Limit, Covered Expenses are divided into the following three (3) categories:
CATEGORY 1:
This category applies to such Covered Expenses made by all EPO Hospitals. For Employees who reside or work outside the EPO service area (50 miles or more from the nearest Preferred Provider), Covered Expenses for Non-Preferred Provider services and supplies shall be Category 1 expenses.
CATEGORY 2:
This category applies to such Covered Expenses made by all other Exclusive Providers and such Covered Expenses made by Providers that are not Exclusive Providers if:
1. Such expenses are made by pathologists, radiologists, or anesthesiologists in connection with a covered Inpatient Exclusive Provider Hospital Confinement or a covered Outpatient procedure performed in an Exclusive Provider Hospital.
2. Such Expenses are necessitated by an Emergency condition (as defined in the Plan), and then only to the following extent: (a) in the case of Emergency Outpatient treatment, such expenses are incurred within twenty-four (24) hours of the accident; and (b) in the case of an Inpatient Hospital Confinement, such expenses up to the day the Covered Person can reasonably be expected to safely transfer to an Exclusive Provider.
3. Such expenses are for care, treatment, services, or supplies that are not rendered by any Exclusive Provider.
4. Such expenses are incurred while traveling outside of the Preferred Provider area (50 miles or more from the nearest Preferred Provider).
CATEGORY 3:
This category applies to such Covered Expenses made by all other Non-EPO Providers.
If the Covered Person elects to use a Non-Exclusive Provider, the Coinsurance payable by the Covered Person shall not apply to the Out-of-Pocket Expense Limit.
Out-of-Pocket Expense Limit per
Calendar Year:
|
|
Individual |
$ 1,500 |
|
|
Family (Aggregate) |
3,000 |
Refer to the section entitled Medical Expense Benefit, Out-of-Pocket Expense Limit for a listing of charges not applicable to the Out-of-Pocket Expense Limit.
The Plan pays the percentage listed on the following pages for Covered Expenses incurred by a Covered Person during a Calendar Year after the Individual or Family Deductible has been satisfied and until the Individual or Family Out-of-Pocket Expense Limit has been reached. Thereafter, the Plan pays 100% of incurred Covered Expenses for the remainder of the Calendar Year or until the Maximum Benefit has been reached. Refer to the section entitled Medical Expense Benefit, Out-of-Pocket Expense Limit for a listing of charges not applicable to the 100% Coinsurance.
PLAN C Benefit
Description |
EPO Provider Category 1 |
(see Page 7) Category 2 |
Non-EPO Provider Category 3 |
|
|
INPATIENT HOSPITAL* |
100%
Ded. Waived* |
80% |
Network
only** |
|
|
|
* Benefits
for Inpatient Hospital Expenses will be subject to a separate and additional $300
Deductible and 80% Coinsurance per unapproved admission. |
|||
|
|
** Emergency
admissions to Non-Network providers will be covered at the EPO Benefit level
provided Covered Person is transferred to a Network provider as early as possible. See Plan Document for details. |
|||
|
|
|
|
|
|
|
OUTPATIENT SURGERY* |
100%* |
80% |
NETWORK ONLY |
|
|
|
* Benefits
for Outpatient Surgery expenses will
be subject to a separate and additional $300
Deductible and 80-20% Coinsurance payment per unapproved surgical procedure. |
|||
|
|
|
|
|
|
|
ER SERVICES * |
100% after $100 Co-pay |
100% after $100 Co-pay |
100% after $100 Co-Pay |
|
|
|
* The
$100 Co-payment is waived if Covered Person is admitted to the Hospital; coverage
reverts to Hospital Inpatient as noted above. |
|||
|
|
|
|
|
|
|
URGENT CARE |
100% subj. to $15 Co-pay |
80% subj. to $15 Co-pay |
60% subj. to $15 Co-pay |
|
|
|
|
|
|
|
|
SUPPLEMENTAL ACCIDENT |
100% Ded. Waived up to $500.* |
100% Ded. Waived up to $500.* |
100% Ded. Waived up to $500.** |
|
|
|
* Limitation: Maximum Benefit $500 per accident;
coverage then reverts to Plan Benefits. |
|||
|
|
|
|
|
|
|
PRE-ADMISSION TESTING |
100% |
80% |
60% |
|
|
|
|
|
|
|
|
PHYSICIANS’ SERVICES |
|
|
|
|
|
N/A |
100% after $15 co-pay |
60% |
||
|
|
|
|
|
|
|
80% |
80% |
80% |
||
|
|
Assistant Surgeon’s Covered Expenses not to exceed 20% of the primary Physician’s Covered Expenses. |
|||
|
|
|
|
|
|
|
SECOND SURGICAL OPINION |
|
|
|
|
|
N/A |
100% Ded. Waived |
60% |
||
|
|
|
|
|
|
|
N/A |
100% Ded. Waived |
60% |
||
|
|
|
|
|
|
|
OUTPATIENT
DIAGNOSTIC |
|
|
|
|
|
|
*Services ordered by an EPO Physician and
rendered as part of the EPO Physician
office visit shall be considered part of the EPO Physician office visit
Co-payment, whether or not the services are performed on the same day as the
office visit. Excluded from this
provision is lab work ordered for review and maintenance of a medical
condition, such as monthly visits to a lab for blood work. See “All
Other Outpatient Diagnostic X-rays and Laboratory” for benefit. |
|||
|
|
|
|
|
|
|
ALL OTHER OUTPATIENT DIAGNOSTIC X-RAYS AND LABORATORY |
|
|
|
|
|
|
|
|
|
|
|
EXTENDED CARE FACILITY |
N/A |
80% |
60% |
|
|
|
Limitation: Up to 30 days for treatment and Confinement per Calendar Year. |
|||
|
|
|
|
|
|
|
HOME HEALTH CARE |
N/A |
80% |
60% |
|
|
|
|
|
|
|
|
HOSPICE CARE |
N/A |
80% |
60% |
|
|
|
Limitation: Maximum Benefit per family unit for bereavement counseling is
$200. |
|||
|
|
|
|
|
|
|
DURABLE MEDICAL EQUIPMENT |
N/A |
80% |
60% |
|
|
|
Limitation: Maximum Benefit per Calendar Year not to exceed 100 days
rental; Maximum Benefit per Calendar
Year for rental of Apnea Monitor (except if used for infants), T.E.N.S. Unit
or equipment designed to assist bones to knit faster is limited to $200 each. |
|||
|
|
|
|
|
|
|
PREVENTIVE CARE |
N/A |
100% to $300* Co-Pay and Ded. Waived |
Denied |
|
|
|
*Limitation: Up to $300 per Calendar Year benefit. |
|||
|
|
|
|
|
|
|
MENTAL
AND |
|
|
|
|
|
|
*Subject to a maximum of 30 days
per calendar year Inpatient services. *Outpatient services subject to $15 co-pay and maximum 25 visits per calendar year. |
|||
|
|
|
|
|
|
|
CHEMICAL DEPENDENCY |
|
|
|
|
|
Inpatient Services |
100%* |
80%* |
60%* |
|
|
|
*Limitation: $10,000 per Covered Person per Calendar Year for Inpatient and
Outpatient Hospital |
|||
|
|
|
|
|
|
|
Outpatient Services |
N/A |
50%* |
50%* |
|
|
|
*Limitation: $2,000 per Covered Person per Calendar Year (included in the Inpatient and/or Outpatient limit of $10,000). |
|||
|
|
|
|
|
|
|
PHYSICAL THERAPY |
N/A |
80% |
60% |
|
|
|
|
|
|
|
|
SPEECH THERAPY |
N/A |
80% |
60% |
|
|
|
|
|
|
|
|
CHIROPRACTIC CARE |
N/A |
100%* |
N/A |
|
|
|
*Maximum Benefit: $25 per treatment; Maximum of 26 treatments per Calendar
Year. |
|||
|
|
|
|
|
|
|
AMBULANCE |
N/A |
80% |
N/A |
|
|
|
|
|
|
|
|
BIRTHING CENTER |
N/A |
100% |
N/A |
|
|
|
|
|
|
|
|
ALL OTHER COVERED EXPENSES |
N/A |
80% |
80% |
|
|
|
|
|
|
|
|
PRESCRIPTION DRUGS |
N/A* |
N/A* |
N/A* |
|
|
|
100% after Prescription Drug Co-pay; $5 generic/$15 brand name. Generic will be dispensed unless specified “Dispense as Written.” Maintenance drugs will be dispensed through a mail order program. |
|||