Medical Benefits summary
| Description | In-Network | Out-of-Network | |
| Copayments | A specific charge you will pay at time of service; then, for most services, the plan covers the remainder. Copays DO NOT apply to your deductibles, or breakpoint maximums. | $20 Dr Office Visit & $100 Emergency Room Visit | N/A for Office Visits - $100 for Emergency Room Visit |
| Coinsurance | Percentage of the bill you'll pay after you've satisfied your deductibles. | 10% | 40% |
| Deductibles | The amount you must play each Calendar Year to cover your medical expenses before your plan starts paying. | $500 per individual & $1,500 per family | $1,000 per individual & $3,000 per family |
| Per Confinement Deductible (PCD) | The amount of money you must pay for each inpatient service and outpatient surgery before your plan starts paying. This is IN ADDITION to the normal Calendar Year deductibles. | NONE | $500 |
| Average Contracted Rate (ACR) | The rate NETWORK PROVIDERS have agreed to charge. Services received from non-network providers are subject to the difference between this rate and the non-network provider's actual rate. See the Allowable Covered Expenses flier for more details. | ||
| Service | Description | In-Network | Out-of-Network |
| Physician Office Visit | Visits to a provider for routine, non-emergency care. Non-network services are subject to the calendar year deductible and coinsurance. | $20 per visit | 40% |
| Preventative Care | Includes routine physical exams, including immunizations and basic gynecological care. Limited to 1 exam annually for members over the age of 2. Lab and x-ray services are subject as described below. | $20 per visit | 40% |
| Prescription Drugs (including oral contraceptives) | Prescriptions filled at a network pharmacy are subject to the generic, brand, or non-preferred brand name copayment level. If you need maintenance drugs and use our mail order program, your copayments will only be 2X the pharmacy copayment, but you will receive a 3 month supply. Service is provided by AdvanceRx at www.AdvanceRx.com | $10 Generic - $20 Preferred Brand & $40 Non-preferred Brand | The appropriate copayment level PLUS 50% of the full cost of the prescription |
| Inpatient Hospital Services | Includes room, board, services and supplies. Facility charges are subject to the "per confinement" deductibles (if using an out-of-network facility) and coinsurance. Non-inpatient facility services are subject to the calendar year deductibles and coinsurance. | 10% | $500 Per Confinement Deductible PLUS 40% |
| Outpatient Surgery | Procedures performed in an outpatient facility are subject to the "per confinement" deductible and coinsurance. | 10% | $500 Per Confinement Deductible PLUS 40% |
| Office Surgery | Surgery performed in a contracted doctor's office is subject only to the coinsurance. The deductible is WAIVED. | 10% | 40% |
| Lab & X-Ray | These services are subject only to the coinsurance. The deductible is WAIVED. | 10% | 40% |
| Emergency Room Care | Subject to the Emergency Room copayment for physician services. Lab and x-ray services are subject, as described above. | $100 Copayment - The cost of this service is the same regardless of network status. | |
| Ambulance | Subject to the in-network calendar year deductible and coinsurance. | 10% - The cost of this service is the same regardless of network status. | |
| Outpatient Physical Therapy | Subject to the applicable calendar year deductible and coinsurance. Coverage is limited to $2,000/person per calendar year. | 10% | 40% |
| Outpatient Speech, Hearing & Occupational Therapies | Subject to the applicable calendar year deductibles and coinsurance. Coverage is limited to $2,000 per calendar year. | 10% | 40% |
| Inpatient Mental Health & Chemical Dependency | Services rendered in-network are subject to the per confinement deductible and coinsurance. Non-network services are subject to the applicable calendar year deductibles and coinsurance. These services are limited to 5 days per year and 10 days per lifetime maximum. | 10% | $500 Per Confinement Deductible PLUS 40% |
| Outpatient Mental Health | Services rendered in-network are subject to an outpatient mental health copayment. Non-network services are subject to the applicable calendar year deductibles and coinsurance. These services are limited to 20 visits per year. | $35 | 40% |
| Durable Medical Equipment | Subject to the applicable calendar year deductibles and coinsurance. Coverage is limited to a $10,000 lifetime maximum per covered person. | 10% | 40% |
| Skilled Nursing Facility | Subject to the hospital services benefits. Coverage is limited to 100 days per calendar year. | 10% | $500 Per Confinement Deductible PLUS 40% |
| Home Health Care | Subject to the applicable calendar year deductibles and coinsurance. Coverage is limited to 1 visit per day for 100 days per calendar year. | 10% | 40% |
| Hospice Care | Subject to the per confinement deductible and coinsurance. | 10% | $500 Per Confinement Deductible PLUS 40% |
| Breakpoint | Once you reach the individual breakpoint in any one calendar year, covered services will by payable at 100% for the remainder of the year. | $10,000 per individual - $30,000 per family | |
| Lifetime Plan Maximum | The maximum amount payable by your plan during the entire time you're covered by this specific plan. | $1,000,000 per member | |
| Out of Service Area Services | Services received outside of any PPO geographical area are paid at 80% of usual and customary charges and are subject to the non-network deductibles and coinsurance breakpoint. | ||