Overview |
Your medical benefits are designed to substantially cover most forms of medically necessary care. This coverage is subject to various deductibles, copayments, coinsurance, and other limits. |
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Deductibles
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Before any payments are made by the plan you must satisfy the annual deductible.
Individual
$200 per calendar year
Family
$400 per calendar year.
The maximum total deductible for all family members combined.
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Copayments
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For the services shown you must pay a copayment, which does not apply towards the deductible.
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PPO |
NON-PPO |
| Office Visit |
$10 |
$20 |
| Emergency Room Visit |
$50 |
$50 |
| Inpatient Hospital Admission |
$0 |
$200 |
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Coinsurance
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The portion (percentage) of the charges that the plan pays after the deductible
has been satisfied and after any copayment has been paid.
There are three general levels of coinsurance based on the type of medical
care.
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Plan Pays
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You Pay
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90%
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10%
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80%
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20%
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50%
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50%
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90-10: Each individual's coinsurance is limited to an annual maximum of $2,300.
80-20 and 50-50: Coinsurance paid in these categories does not apply to the
annual coinsurance maximum.
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Other Out-of-Pocket Expenses |
Are those which are not covered by the plan and for which you are responsible.
Non-PPO providers may charge amounts in excess of the UCR (usual, customary and reasonable) amounts allowed by the plan. Charges for services that exceed your annual maximum or a specific maximum or limit. Charges which are not medically necessary including care not approved through the medical review process.
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Annual Maximum |
$325,000 per calendar year per individual (change effective 1/1/2008)
Other individual benefit maximums may apply within this limit. |
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PPO |
You are encouraged to receive all of your medical care from providers who are members of the plan's PPO network.
Copayments for some types of care are less. Your coinsurance will be the percentages shown below. PPO provider must directly bill the Plan, rather than making you pay and then request reimbursement.
Click here to locate PPO providers.
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Medical Review |
The set of programs to help ensure that you receive appropriate care. Penalties may apply if you neglect to use the medical review required by the plan.
Preadmission certification is mandatory to predetermine the length of any hospital admission. Second surgical opinions are required (and paid for at 100%) for certain procedures. Case management helps you to control costs of expensive or long-term forms of care. |
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Most Common Medical Services |
Click here for list of benefits
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