| |
| Lifetime Maximum Benefit - $2,000,000 per person |
| |
| Description of Benefits |
Copayment (Amount you pay per visit)
In Network Only |
Benefit Amount with a
Preferred Provider |
Benefit Amount with an
Out of Network Provider |
Special Conditions |
| Amounts are a % of the allowed charge after in-network deductible has been met |
Amounts are a % of the allowed charge after out-of-network deductible has been met |
Before
out-of-pocket maximum is met |
After
out-of-pocket maximum is met |
Before
out-of-pocket maximum is met |
After
out-of-pocket maximum is met |
| |
| Hospital Services |
| Inpatient |
|
90% |
100% |
70% |
100% |
Preauthorization may be required. |
| Outpatient |
|
90% |
100% |
70% |
100% |
| Professional Health Care Provider Services |
Inpatient,
Outpatient and
Surgical
Services |
|
90% |
100% |
70% |
100% |
|
| Home and Office Visits |
$20 |
90% |
100% |
70% |
100% |
Deductible does not apply in-network. |
| Wellness Services |
Maximum benefit of $500 per calendar year per person. |
Routine Physical
Exams |
$20 |
100% |
100% |
70% |
100% |
Deductible does not apply in-network. |
Well Child Care to
age 6 |
$20 |
100% |
100% |
70% |
100% |
Deductible does not apply in-network. |
| Diagnostic Services |
| Lab, X-ray, MRI |
|
90% |
100% |
70% |
100% |
|
| Colonoscopy |
|
90% |
100% |
70% |
100% |
Deductible does not apply. |
| Mental Health/Chemical Dependency Services |
Preauthorization may be required. |
| Inpatient |
|
90% |
100% |
70% |
100% |
10 visits maximum per calendar year; 30 visits maximum per lifetime. |
| Outpatient |
$20 |
90% |
100% |
70% |
100% |
Copay and coinsurance applicable to first 10 hours in-network per calendar year; additional hours subject to deductible and coinsurance. 40 hours maximum per calendar year. |
| Emergency Services |
Ambulance
Services |
|
90% |
100% |
70% |
100% |
|
Emergency
Room Charge |
$75 |
90% |
100% |
70% |
100% |
Deductible does not apply in-network. |
| Urgent Care Services |
Professional
Health Care
Provider Visit |
|
90% |
100% |
70% |
100% |
|
Emergency
Room Charge |
$25 |
90% |
100% |
70% |
100% |
Deductible does not apply in-network. |
| Chiropractic Services |
12 visits per Calendar Year Max, additional visits require authorization. |
Home and Office
Visits |
$20 |
90% |
100% |
70% |
100% |
Deductible does not apply in-network. |
Therapy and
Manipulations |
$20 |
90% |
100% |
70% |
100% |
Deductible does not apply in-network. |
Diagnostic
Services |
|
90% |
100% |
70% |
100% |
|
| All Other Eligible Expenses |
|
90% |
100% |
70% |
100% |
|
| Description of Benefits |
Benefit Before Prescription Drug Coinsurance Maximum
is Met |
Benefit After Prescription Drug Coinsurance Maximum is Met |
Special Conditions |
| Outpatient Prescription Medications and Drugs (Retail) |
Copayment |
Coinsurance |
Copayment |
Coinsurance |
Dispensing Limits:
~34-day supply or 100 units (the greater of) |
| Generic |
$15 |
100% |
$15 |
100% |
| Single Source Brand Name |
$15 |
80% |
$15 |
100% |
| Multi Source Brand Name |
$30 |
70% |
$30 |
100% |
| Outpatient Prescription Medications and Drugs (Mail Order) |
Copayment |
Coinsurance |
Copayment |
Coinsurance |
Dispensing Limits:
~90 Day supply |
| Generic |
$30 |
100% |
$15 |
100% |
| Single Source Brand Name |
$30 |
80% |
$15 |
100% |
| Multi Source Brand Name |
$60 |
70% |
$30 |
100% |
| Outpatient Prescription Drug Copay/Coinsurance Maximum Amount |
$1500 per member per calendar year |
When the prescription drug copay/coinsurance maximum amount has been met, copayment amounts will continue to apply, and prescription drugs will be covered at 100% of the allowed charge for the remainder of the calendar year. |
PRIMARY PROVIDER NETWORK: Noridian
DEPENDENT CHILDREN: Eligible until age 19, or until age 25 if a full-time student |
Plan 250
