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| HOSPITAL (including Mental Health and Substance Abuse Treatment)
| NETWORK PROVIDER | NON-NETWORK PROVIDER | |
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| Calendar Year Deductible | Blue Cross/BlueCard/ValueOptions
$250/person;
$500/family
Industry Health Network
$150/person
$300/family
| Not covered | |
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| Inpatient (Room/Board/Ancillary Svcs.) | 90% | Not covered | |
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| Outpatient Surgery | 90% | Not covered | |
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| Emergency Room | 90% after $100 co-pay; co-pay is waived if patient admitted | Not covered* | |
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| Out-of-Pocket Maximum (excludes Deductible and Co-Pays) | $1,750/person;
$3,500/family | Not covered | |
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| *Emergency treatment within 72 hours after an accident or within 24 hours of a sudden
and serious illness will be covered at the Network level of benefits. | |
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MAJOR MEDICAL (including
Mental Health and Substance
Abuse Treatment)
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|
| Calendar Year Deductible | Blue Cross/BlueCard/ValueOptions
$250/person;
$500/family
Industry Health Network
None
| $500/person;
$1,000/family
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| Office Visit/X-Ray/Lab | 90% after $15 co-pay | 70% | |
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| Surgeon - Inpatient
| 90% after $100 co-pay | 70%
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| - Outpatient |
90% after $100 co-pay for surgery in the outpatient department of the hospital, a freestanding surgical center,
or a physician's surgical suite
| 70%
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| 90% after $15 co-pay for surgery in a doctor's office | 70%
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| Surgical Suite | Covered under
Hospital Benefits | A surgical suite is a site, either in a doctor's office or an independent facility, where outpatient surgery
is performed. If the surgery for you or a dependent takes place in a non-network surgical suite or ambulatory surgical center,
the Plan will allow up to $1,000 for use of the suite's operating and recovery rooms and all central supplies.
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| Maternity Care | 90% after $100 co-pay (per pregnancy) | 70% | |
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| Routine Physical Exam
| No deductible; 100% | No deductible; 70% | |
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| Routine Child Exam | No deductible; 100% | No deductible; 70% | |
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| Mammogram/Pap | No deductible; 100% | No deductible; 70% | |
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| Other Benefits
| The following benefits are also available subject to specific rules:
Therapy,
Outpatient Nursing,
Case Management.
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| Out-of-Pocket Maximum (excludes Deductible and Co-Pays) | $1,000/person;
$2,000/family | $2,500/person;
$5,000/family | |
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| Hospital/Major Medical Lifetime Maximum | None | |
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PRESCRIPTION DRUGS | | | |
|
| Calendar Year Deductible | $150 per individual/$300 per family
This is a combined deductible for retail and mail order. Charges at both the retail and mail service pharmacies will be used to satisfy the deductible. |
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| Retail Pharmacy | You will pay the greater of the two co-payments shown:
- Generic: $10 or 10%
- Preferred Brand: $25 or 25%
- Non-Preferred Brand: $40 or 40%
In addition, if you receive a brand-name drug when a generic exists, you will pay the difference in cost between the generic and brand-name medication. | |
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| Medco by Mail (includes Accredo speciality)
| You will pay the greater of the two co-payments shown:
- Generic: $20 or 10% maximum co-pay is $50 per prescription
- Preferred Brand: $50 or 25% maximum co-pay is $125 per prescription
- Non Preferred Brand: $100 or 40% maximum co-pay is $300 per prescription
In addition, if you receive a brand-name drug when a generic exists, you will pay the difference in cost between the generic and brand-name medication. | |
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MENTAL HEALTH AND SUBSTANCE ABUSE
| ValueOptions Provider | Non-Network Provider | |
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| Hospital and Alternative Levels of Care | Covered under the Hospital Benefit | Not Covered | |
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| Major Medical | Covered under the Major Medical Benefit | Covered under the Major Medical Benefit | |
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MENTAL HEALTH
These Benefits will continue to be administered by ValueOptions, however, as a result of the Mental Health Parity law the benefit levels will be the same as the Hospital/Major Medical Benefits outlined above. | |
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CHEMICAL DEPENDENCY
These Benefits will continue to be administered by ValueOptions, however, as a result of the Mental Health Parity law the benefit levels will be the same as the Hospital/Major Medical Benefits outlined above. | |
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