Current employees can only enroll or make changes in the month of
September. Changes will take affect October 1st. Please do not let this
opportunity pass by.
| FEATURES |
| MEDICAL CALENDAR-YEAR
DEDUCTIBLE |
$0 |
| PHARMACY CALENDAR-YEAR
DEDUCTIBLE |
$250 for brand prescriptions |
ANNUAL OUT-OF-POCKET MAXIMUM1
Individual/Family |
$3,500/$7,000 |
| IN THE MEDICAL OFFICE |
| Office visits |
$30 |
| Preventive exams |
$30 |
| Maternity/prenatal care2 |
$0 |
| Well-child preventive
care visits3 |
$0 |
| Vaccines
(immunizations) |
$0 |
| Allergy injections |
$5 |
| Infertility services |
Not covered |
| Occupational, phycal,
and speech therapy |
$30 |
| Most labs and imaging |
$10 |
| MRI/CT/PET |
$50 |
| Outpatient surgery |
$200 |
| Chiropractic care |
$15 20-visits per year |
| EMERGENCY SERVICES |
| Emergency Department
visits (waived if admitted directly to hospital) |
$100 |
| Ambulance |
$75 |
| PRESCRIPTIONS4 |
(up to a 100-day supply) |
| Generic |
$105 |
| Brand |
$35 (after pharmacy deductible) |
| HOSPITAL CARE |
| Physicians services,
room and board, test, medications, supplies, therapies |
$400 per day |
| Skilled nursing
facility care (up to 100 days per benefit period) |
$0 |
| MENTAL
HEALTH SERVICES6 |
| In the medical office
(up to 20 visits per calendar year) |
$30 individual
$15 group |
| In the hospital (up to
30 days per calendar year) |
$400 |
| CHEMICAL DEPENDENCY SERVICES |
| In the medical office |
$30 individual |
| In the hospital
(detoxification only) |
$400 per day |
| OTHER |
| Certain durable medical
equipment (DME) DME used in the home in accord with our DME
formulary |
Not covered7 |
| Optical (eyewear) |
Not covered |
| Vision exam |
$30 |
| Home health care (up to
100 two-hour visits per calendar year) |
$0 |
| Hospice care |
$0 |
| 1The
annual out-of-pocket maximum is the limit to the total amount
that an individual or family must pay for certain services in a
calendar year (as discussed int the Evidence of Coverage). |
| 2Scheduled
prenatal visits and the first postpartum visit. |
| 323
months or younger. |
| 4Prescription
drugs are covered in accord with our formulary when prescribed
by a plan physician and obtained at Plan pharmacies. A few drugs
have different copayments; please refer to the Evidence of
Coverage for detailed information about prescription drug
copayments. |
| 5This
service is not subject to a deductible. |
| 6Visit
or day limits do not apply to serious emotional disturbances of
children and severe mental illnesses as described in the
Evidence of Coverage. |
| 7Please
refer to the Evidence of Coverage for more information; most DME
is not covered. |
