|
|
|
|
 |
|
MEDICAL |
The Plan's medical
benefits cover a large part of your expenses
for treatment of non-work related illnesses
(including pregnancy) or accidental injuries,
and protect you and your family in the event
of catastrophic illnesses.
|
|
 |
|
|
|
Active Summary of Benefits as of June
1, 2007
|
|
Calendar Year Deductible |
$250
per person; $500 per family |
| Non-PPO
Hospital Deductible |
$500
per person for each non-emergency admission to a non-PPO
hospital |
|
Calendar Year Out-of-Pocket
Maximum |
|
|
Combined PPO and Non-PPO Maximum |
$2,500 per person; $5,000 per family |
|
Additional Non-PPO Maximum |
$1,000 per person; $2,000 per family |
Lifetime Maximum
|
$1,000,000 per person |
| Well
Baby Care |
$1,000 per dependent child up to age two |
|
Chiropractic/Spinal Care |
$5,000 per person |
|
Substance Abuse Treatment |
$25,000 per person |
|
Inpatient Treatment |
One
21-day course of treatment per person |
|
Infertility Treatment |
$10,000 |
Calendar Year Maximums
|
|
|
Chiropractic/Spinal Care |
$1,000 per person |
|
Substance Abuse Treatment |
$10,000 per person |
|
Mental Health Treatment |
|
|
Inpatient Maximum |
15
days per person with up to 15 physician visits |
|
Outpatient Maximum |
30
visits per person |
|
Speech Therapy |
30
visits per person |
|
Outpatient Physical, Speech, and Occupational Therapy |
$5,000 per dependent child (diagnosed with congenital,
neurological disease) (Speech therapy limited to 30 visits per
year) |
|
Specific Benefit Maximums |
|
|
Routine Physical Exam |
$600
per person every two years for Member and
Spouse |
|
Hospital Daily Room And Board |
Semi-private room rate |
|
Hospital Intensive Care |
Three
times semi-private room rate |
|
Hearing Aid Program |
$600
per person every three years |
| |
|
Type of Service |
PPO Provider |
Non-PPO Provider |
|
Outpatient Pre-Admission Tests |
Plan pays 100%; no deductible |
Plan
pays 100%; no deductible |
|
Hospital Benefits |
Plan pays 90% |
Plan
pays 70% |
| Well
Baby Care |
Plan pays 80%; no deductible |
Plan
pays 70%; no deductible |
|
Routine Physical Exam (for employees and dependent spouses) |
Plan pays 100%; no deductible |
Plan
pays 100%; no deductible |
|
Mammograms |
Plan pays 100%; no deductible |
Plan
pays 100%; no deductible4 |
| Colon
Cancer Screenings |
Plan pays 100%; no deductible |
Plan
pays 100%; no deductible |
|
Chiropractic/Spinal Care |
Plan pays 80% |
Plan
pays 70% |
|
Substance Abuse Treatment |
|
|
|
Inpatient Treatment |
Plan pays 90% |
Plan
pays 70% |
|
Outpatient Treatment |
Plan pays 90% of first $5,000 in a year; 50% thereafter |
Plan
pays 50% |
|
Mental Health Treatment |
|
|
|
Inpatient Treatment |
Plan pays 90% |
Plan
pays 50% |
|
Outpatient Treatment |
Plan pays 50% |
Plan
pays 50% |
|
Hearing Aid Program |
Plan pays 100% |
Plan
pays 100% |
|
Ambulatory Surgical Center |
Plan pays 90% |
NOT
COVERED |
| For
All Other Covered Medical Expenses |
Plan pays 80% |
Plan
pays 70% |
| |
|
|
|
|
|
|
|
