Medical &Dental Benefits

Medical Benefits In-Network Benefits Out-of-Network Benefits
Medical Deductibles. $500 Individual
$3x Family		 $1000 Individual
$3x Family
Out of Pocket Maximums
(Calendar Year, does not include deductible)		 $3000 Individual
2x Family		 $6000 Individual
2x Family
Medical Maximum $1,000,000 Lifetime Maximum, except as shown
Physicians Office Visit 100% after $20 copay
Specialist copay $30		 60% after deductible
Allergy Shots (injections) 100%* 60% after deductible
Physical Therapy
(24 visits per Calendar Year)		 80% after deductible

 60% after deductible
up to $20 per visit
TMJ Surgery 80% after deductible 60% after deductible
Allowable Non-Surgical Back Treatment
($1,000 per Calendar Year)

80% after deductible 60% after deductible
Diagnostic X-ray & Lab 80% after deductible 60% after deductible
Preventive Care
Well Child Care (birth to age 18) 100%* 60% after deductible
Immunizations (birth to age 18) 100%* 60% after deductible
Annual Pap Smears
(including Office visit/lab charges)		 100%* 60% after deductible
Colorectal/prostate Screenings 100%* 60% after deductible
Mammogram Screening 100%* 60% after deductible
Adult Physical (age 18 and over)
(Maximum $250 per Calendar Year)		 100%* 60% after deductible
*If there is an office visit associated with this service, the copay will apply.
Note: Associated lab work is paid at in-network level if done at an in-network hospital.
Hospital and Other Charges
Hospital Room &Board 80% after deductible 60% after deductible
Inpatient Hospital per Admission copay NA $250
Outpatient Surgery Copay $100 $250
Emergency Room Charges 100% after $100 copay
(Waived if admitted)		 100% after $100 copay
(Waived if admitted)
Ambulance Services 80% after deductible 80% after deductible
Maternity Services 80% after deductible 60% after deductible
Same Day (Outpatient) Surgery 80% after deductible 60% after deductible
Anesthesiologists, Radiologists, Pathologists 80% after deductible 60% after deductible
Mental Health, Substance Abuse
Inpatient/Outpatient Mental Health
(30 days per Calendar Year)		 80% after deductible 60% after deductible
Inpatient/Outpatient Substance Abuse
(30 days per Calendar Year)		 80% after deductible 60% after deductible
Inpatient and Outpatient Substance Abuse includes a combined Lifetime Maximum of $16,000.
Prescription Drugs at Participating Pharmacies
WellPoint Rx and Mail Order Services*
(including diabetic supplies and contraceptives)		 $10 Generic / $25 Brand Formulary / $50 Brand Non-Formulary (30 day supply)
MOD-2x for 90 days
Self-injectable drugs (other than insulin) In Network: 20% coinsurance up to $100 max per prescription with annual OOP max of $5,000
Out of Network: 50% coinsurance
Out of Network Pharmacy Applicable copay plus 25% coinsurance
*Not all pharmacies participate in the extended refill benefit. Please read the prescription drug plan member handbook carefully.
eEAP-Employee Assistance Program 1-800-999-7222
24 hour access: Professional phone consultations and online resource
The following expenses will not be applied toward satisfaction of the out of pocket maximum or toward benefits payable at 100%
Calendar Year Deductible
Copayments
Outpatient Treatment of Mental Health and/or Substance Abuse
Any Cost Containment Provision Policy
Charges in excess of Reasonable and Customary
Pre-authorization is required for all inpatient hospital admissions and selected outpatient procedures There is a $500 reduction of benefits for non-compliance.
Pre-authorization is also required for Skilled Nursing and Home Health Care. If benefits are not pre-authorized, no benefit will be paid.
Compliance with State Mandated Benefits.
Dental Benefits
Calendar Year Deductible $50 per Person
$150 per Family
Preventive Care Plan pays 100% (deductible waived)
Basic Care Plan pays 80% after deductible
Major Care Plan pays 50% after deductible
Calendar Year Maximum Plan pays $1,000 per year
Orthodontia Care Plan pays 50%
Orthodontia Maximum Plan pays $1,000 per year