Summary Chart of Medical Benefits – 2002
 

Enhanced PPO

Basic PPO

Plan Features

If you see a Network provider

If you see a Non-network provider

If you see a Network provider

If you see a Non-network provider

Physician Services

        
bullet Office Visits
bullet Hospital Visits
bullet Inpatient Surgery
bullet Outpatient Surgery
bullet Hospital Newborn Care
bullet Spinal Adjustments
(up to 12 visits/cal. year)

100% after $15 copay/office visit

100% hospital visits and surgery

(deductible does not apply)

 

60% of R&C*

(deductible applies)

 

80%

(deductible applies)

 

60% of R&C*

(deductible applies)

 

Outpatient
Prescription Drugs

100% after copay
$10 generic
$30 brand name
Mail Order
(90-day supply)
100% after copay
$20 generic
$60 brand name
(deductible does not apply)

 

 

Not covered

 

 

80% generic
60% brand name

Mail Order
(90-day supply)
80% gen/60% brand
of 60-day cost

(deductible and

coinsurance maximum do not apply)


Not covered

Preventive Care

100% after $15 copayment/office visit up to $300/person
each calendar year
(deductible does not apply)

 

Not covered

Office visits not covered; 80% for one Pap test/cal. yr
80% for mammogram per age schedule
(deductible applies)

 

Not covered

Well Baby Care

100% after $15 copayment/office visit up to 2nd birthday
(deductible does not apply)

 

Not covered

 

Not covered

 

Not covered

Health Care Facility

bullet Hospital Inpatient**
(room and board, x-rays, intensive care, newborn routine nursery care)
bullet Hospital Outpatient (minor surgery, radiation therapy)
bullet Skilled Nursing Facility** (room&board up to semiprivate room rate,
up to 120 days/cal. yr)
bullet Home Health Care**
(up to 130 visits/cal. year)
bullet Hospice Care**
(up to $5,000 maximum)





100%
(deductible does not apply)





60% of R&C*
(deductible applies)





80%
(deductible applies)





60% of R&C*
(deductible applies)
Hospital
Emergency Room Care

100% after $75 copay
for emergencies
(deductible does not apply)

80% after $75 copay for non-emergencies (deductible applies)

 

(copayment is not waived even if admitted)

100% of R&C* after $75 copay for emergencies
(ded does not apply)

60% of R&C* after $75 copay for non-emergencies (deductible applies)

80% for
emergencies
(deductible applies)

60% for non-emergencies (deductible applies)

80% of R&C* for emergencies
(deductible applies)

60% of R&C* for non-emergencies (deductible applies)

Urgent Care Centers

100% after $30 copayment/visit (deductible does not apply)

60% of R&C*
(deductible applies)

80%
(deductible applies)

60% of R&C*
(deductible applies)

Second Surgical Opinion Program

bullet Physician Services
bullet Related Diagnostic Procedures
bullet X-rays (medically necessary)

 

 

100%
(deductible does not apply)

 

 

60% of R&C* (deductible applies)

 

 

80%
(deductible applies)

 

 

60% of R&C* (deductible applies)
Other Covered Major Medical Benefits:
bullet Ambulance Service
bullet Artificial Limbs or Eyes
bullet Durable Medical Equipment (rental)



80%
(deductible applies)



80% of R&C*
(deductible applies)



80%
(deductible applies)

 

60% of R&C*
(deductible applies)
bullet Physical, Speech, Occupational and Respiratory Therapy
bullet Infertility Treatment

80%
(deductible applies)

60% of R&C*
(deductible applies)

    

 

X-Ray and Lab

Anesthesiology

 

100%
(deductible does not apply)

100% when ordered by a network provider

(ded. does not apply)

60% of R&C* when ordered by a non-network provider

(deductible applies)

 

80%
(deductible applies)

80% when ordered by a network provider

(deductible applies)

60% of R&C* when ordered by a non-network provider

(deductible applies)

Mental Health and Chemical Dependency

        
bullet Inpatient Care
(maximums apply; see "Mental Health and Chemical Dependency" section)

 

100%
(deductible and coinsurance maximum do not apply)

 

50% of R&C*
(deductible and coinsurance maximum do not apply)

 

80%
(deductible and coinsurance maximum do not apply)

 

50% of R&C*
(deductible and coinsurance maximum do not apply)
bullet Outpatient Care (maximums apply; see "Mental Health and Chemical Dependency" section)

100%, after $15 copayment
(deductible and coinsurance maximum do not apply)

 

50% of R&C*
(deductible and coinsurance maximum do not apply)

 

80%
(deductible and coinsurance maximum does not apply)

 

50% of R&C*
(deductible and coinsurance maximum do not apply)
bullet Intermediate Care

100%
(deductible and coinsurance maximum do not apply)

50% of R&C*
(deductible and coinsurance maximum do not apply)

80%
(deductible and coinsurance maximum do not apply)

50% of R&C*
(deductible and coinsurance maximum do not apply)

Annual Deductible

$100/person; $200/family

(applies except where specified)

$500/person; $1000/family

(applies except where specified)

Coinsurance Maximum
(Out-Of-Pocket max)

$1,000/person;
$2,000/family

(except where specified)

$5,000/person;
$10,000/family

(except where specified)

$3,500/person;
$7,000/family

(except where specified)

$5,000/person;
$10,000/family

(except where specified)

Maximum Lifetime Benefit

$2,000,000/person

* Reasonable & customary charges. ** Pre-admission certification is required for full plan benefits.

NOTE: Copayments do not apply towards deductible or coinsurance (out-of-pocket) maximum

11-01-01

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