Comprehensive Medical Plan
NATIONAL CHOICE PLAN
COMPREHENSIVE HEALTH COVERAGE
LIFETIME MAMIMUM BENEFIT: $1,000,000 PER MEMBER
CALENDER YEAR MAXIMUM: $250,000 PER MEMBER
**Combined maximum in-network and out-of-network benefits**
|
|
PPO PROVIDER | NON-PPO PROVIDER |
| Annual Deductible (Calender Year) | $500 (3x) | $5,000 (3x) |
| Out-Of-Pocket Maximum (Calender Year) | ||
| Individual | $2,500 | $7,500 |
| Family | $7,500 | $15,000 |
| Hospital Inpatient Benefits | PPO PROVIDER | NON-PPO PROVIDER |
| (Limit per day of $1,250.00) | ||
| Hospital Pre-Admission Co-pay | Subject to Annual Deductible | Subject to Annual Deductible |
| Physician Services | 80% of allowable charges | 60% of allowable charges |
| after Annual Deductible | after Annual Deductible | |
| Inpatient | 80% of allowable charges | 60% of allowable charges |
| after Annual Deductible | after annual deductible | |
| Maternity Care Inpatient | 80% of allowable charges | 60% of allowable charges |
| after annual deductible | after Annual Deductible | |
| Hospital In-Patient Surgery | 80% after Annual Deductible | 60% after Annual Deductible |
| Emergency Room | 80% after $150 Co-pay | 60% after $250 Co-pay |
| Up to$1,250 per Occurrence | Up to $1,250 per Occurrence | |
| Surgery Outpatient | 80% after outpatient Co-pay of | 60% after outpatient Co-pay of |
| $500 per Occurrence | $1,500 per Occurrence | |
| Physician Services | PPO PROVIDER | NON-PPO PROVIDER |
| Primary care office visit | 100% after $25 co-pay | 60% of allowable charges |
| (Max benefit of $100 per visit) | up to 7 visits per member | after annual deductible |
| per year | up to 7 visits per member | |
| per year | ||
| Specialist office visit | 100% after $50 co-pay | 60% of allowable charges |
| (Max benefit of $200 per visit) | up to 7 visits per member | after annual deductible |
| per year | up to 7 visits per member | |
| per year | ||
| Prenatal maternity care in-patient | 80% of allowable charges | 60% of allowable charges |
| (Member or spouse only) | after annual deductible | after annual deductible |
| Urgent Care Facility | 100 % after $50 co-pay | 80% after $150 co-pay |
| (Max benefit of $300 per visit) | per visit up to a maximum | per visit up to a maximum |
| of 7 visits per member | of 7 visits per member | |
| per year | per year | |
| Other facility services | 80% subject to | 60% subject to |
| annual deductible | annual deductible | |
| Chiropractic Care | 100% after $25 co-pay | 80% after $25 co-pay |
| Maximum benefit per visit $100 | per visit | per visit |
| Maximum annual benefit $500 per member | ||
| Preventive Care | 100% after $25 co-pay | No benefits |
| Max of $300 benefit per calender year | up to max annual benefit | |
| per member. Includes physician visit, | ||
| pap smear, PSA, GYN exams, blood work, | ||
| and mammograms for females over age 40 | ||
| or as required by a physician | ||
| Routine well child care (Up to age 7) | 100% after $25 co-pay | No benefits |
| Maximum of $300 annual benefit per | up to max annual benefit | |
| member per year | ||
| Diagnostic lab & x-ray, Oupatient (non | 80% after annual | 60% after annual |
| routine) services up to $1,500 per | deductible | deductible |
| member per year | ||
| Mental health/ Substance abuse | ||
| (Inpatient or outpatient) | ||
| Number of annual visits is a combined | ||
| maximum for both mental health and | ||
| substance abuse care | ||
| Outpatient care visits maximum of 10 visits | 50% after annual | 50% after annual |
| per member per year with a max benefit | deductible | deductible |
| of $100 per visit | ||
| Inpatient care maximum of 10 days per | 50% after annual | 50% after annual |
| member per year. Maximum daily benefit | deductible | deductible |
| of $400 | ||
Substance abuse care both in and out patient is limited to $2,000 per member per calender year.
$5,000 per year maximum for both mental health and substance abuse and $30,000 lifetime maximum benefit.
| Durable medical equipment | 80% after annual | 60% after annual |
| $1,500 per year maximum per | deductible | deductible |
| member (Anything over $100 | ||
| requires pre-certification to be | ||
| covered expense) | ||
| Home health care/ Hospice care | 80% after annual | 60% after annual |
| $5,000 maximum lifetime benefit | deductible | deductible |
| per member (Pre-certification is | ||
| required) | ||
| Other eligible medical expenses | 80% after annual | 60% after annual |
| deductible | deductible | |
| Medical Office Supplies | PPO PROVIDERS | NON-PPO PROVIDERS |
| Syringes and related supplies for | 80% after annual | 60% after annual |
| conditions such diabetes, dressings | deductible | deductible |
| for conditions such as cancer or | ||
| burns, catheters, ostomy bags and | ||
| related supplies, test tape, | ||
| surgical trays and renal dialysis | ||
| supplies (Maximum annual benefit | ||
| of $5,000 per member for medical | ||
| office supplies) | ||
| Ambulance – Up to$300 maximum | 80% after annual | 60% after annual |
| benefit per occurrence | deductible | deductible |
| Skilled nursing care | 80% after annual | 60% after annual |
| Rehabilitation center, skilled nursing | deductible | deductible |
| facility, private duty nursing ($200 | ||
| per day maximum with a max of 15 days | ||
| per member per year | ||
| Therapy (Outpatient) | 80% after annual | 60% after annual |
| Physical, speech, cardiac, pulmonary, | deductible | deductible |
| occupational (Max benefit of $1,000 per | ||
| member per year) | ||
| Transplant Related Expenses | PPO PROVIDER | NON-PPO PROVIDER |
| Pre-approval must be obtained. No benefit | ||
| paid without prior approval being given | ||
| by the insurance company. | ||
| The transplant lifetime maximum | Lifetime Maximum | No Benefits |
| Kidney (Single/Double) | $60,000 | No Benefit |
| Pancreas | $100,000 | No Benefit |
| Heart | $100,000 | No Benefit |
| Lung (Single/Double) | $100,000 | No Benefit |
| Liver | $100,000 | No Benefit |
| Pancreas only | $80,000 | No Benefit |
| Heart and Lung (Single/Double) | $100,000 | No Benefit |
| Bone Marrow | $100,000 | No Benefit |
| Prescription Drug Benefits | PPO PROVIDER | NON-PPO PROVIDER |
| (Outpatient prescription medications) | ||
| Generic Only | $20 Co-pay | No Benefit |
| 100% after Co-pay | ||
| Contraceptives | $20 Co-pay | No Benefit |
| 100% after Co-pay | ||
| Brand Name | 50% Co-pay | No Benefit |
| Maintenance Medications | 90 day supply with | No Benefit |
| 3 prescriptions co-pays | ||
**Express Scripts is the provider for medication**
**$1,500 per year calender maximum per member**
ALL CONDITIONS ARE SUBJECT TO A 12/12 PRE-EXISTING EXCLUSION PERIOD UNLESS MEMBER PROVIDES PROOF OF PRIOR CREDITIBLE COVERAGE. Month for month credit will be given up to the full 12 month period if proof of prior creditable coverage is provided with no more than a 63 day gap from the time prior coverage termed and new coverage begins.
