Medical Benefits

Summary

This plan is a “90-10” plan which means most covered expenses are paid at 90 percent by the plan and at 10 percent by the individual, once the individual’s $200 annual deductible is satisfied. When an individual’s coinsurance reaches $2,300 during a calendar year, the plan pays 100 percent of the covered expenses for the remainder of that calendar year. Benefits for chemical dependency, chiropractic care, mental health care, and neuropsychological assessments or tests are paid at a constant 80 percent (20 percent coinsurance) and the individual’s coinsurance expenses for these services do not apply toward the $2,300 annual coinsurance maximum (except orthognathic surgery). The payment percentage for each benefit is indicated next to the benefit title. If a covered service or supply qualifies under more than one of the benefits described in this section, the plan reserves the right to determine under which benefit payment is made.

This section is comprised of an alphabetical listing of 38 of the most commonly used benefits. Benefits are described in detail, including exclusions specific to that benefit.

Topics Discussed In This Section

Ambulance Transportation
Blood
Chemical Dependency
Chiropractic Care
Dental Accidents
Diabetic Care
Diagnostic X-Ray and Laboratory Services
Durable Medical Equipment
Erectile Dysfunction
Hearing Aids
Home Health Care
Home Phototherapy
Hospice Care
Hospital Services and Supplies
Infusion Therapy
Kidney Dialysis
Medical Supplies
Mental Health Care
Neurodevelopmental Therapy
Neuropsychological Assessments or Tests
Oral Surgery
Orthognathic Surgery
Orthotics
Physician Services
Pregnancy Care
Prescription Drug Benefits
Preventive Care
Prosthetic Devices and Artificial Limbs
Reconstructive Surgery
Rehabilitative Care
Religious Nonmedical Health Care Institutions
Skilled Nursing Facility
Sleep Studies
Sterilization
Surgery
TMJ and MPDS Treatment
Tobacco Cessation Program
Transplants