| HOSPITAL
| NETWORK PROVIDER | NON-NETWORK PROVIDER
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| Calendar Year Deductible | $250/person;
$500/family
Industry Health Network
$150/person
$300/family | $500/person; $1,000/family
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| Inpatient (Room/Board/Ancillary Svcs.) | 100% | 90%
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| Outpatient Surgery | 100% | 90%
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| Emergency Room | 100% after $100 copay; copay is waived if patient admitted | 90%
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| Out-of-Pocket Maximum | N/A | $1,000/person;
$2,000 family
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MAJOR MEDICAL | |
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| Calendar Year Deductible | $250/person;
$500/family
Industry Health Network
No Deductible | $500/person;
$1,000/family
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| Office Visit/X-Ray/Lab | 100% after $15 copay | 80% | |
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| Surgeon - Inpatient
| 100% after $100 copay | 80%
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| - Outpatient |
100% after $100 copay for surgery in the outpatient department of the hospital, a freestanding surgical center, or a physician's surgical suite
| 80%
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100% after $15 copay for surgery in a doctor's office | 80% | |
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| Maternity Care | 100% after $100 copay | 80% | |
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| Routine Physical Exam
| No deductible; 100% after $15 copay | No deductible; 80% | |
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| Well Child | No deductible; 100% after $15 copay | No deductible; 80% | |
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| Well Woman (Mammogram/Pap) | No deductible; 100% after $15 copay | No deductible; 80% | |
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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 (after Deductible) | N/A | $1,000/person; $2,000/family | |
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| Hospital/Major Medical Lifetime Maximum | $2,000,000 under SAG-Producers Health Plan | |
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PRESCRIPTION DRUGS | | | |
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| Calendar Year Deductible | $100 per individual/$200 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 20%
- Brand-name when no generic exists: $20 or 25%
- Brand-name when generic exists: $20 or 25% + difference in price between generic and brand-name.
The Plan will not vary the co-payments according to whether your physician writes, "Dispense as Written" (DAW).
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Home Delivery Pharmacy Service
(Mail Order) | You will pay the greater of the two co-payments shown:
- Generic: $10 or 15%
- Brand-name when no generic exists: $20 or 20%
- Brand-name when generic exists: $20 or 20% + difference in price between generic and brand-name
The new limit on your out-of-pocket expenses for mail order drugs is $75 per prescription (after the deductible).
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MENTAL HEALTH
(All services must be pre-authorized by ValueOptions prior to receiving treatment) | |
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| Inpatient | $250 deductible/calendar year; 100% of contracted charges for up to 45 days/calendar year or 90 days/calendar year for alternative levels of care*
| Not Covered | |
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| Outpatient | $20 copay/visit; maximum 40 visits/calendar year | Not Covered | |
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| * alternative levels of care include: residential treatment center, partial hospitalization programs and intensive outpatient programs. | |
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CHEMICAL DEPENDENCY
(All services must be pre-authorized by ValueOptions prior to receiving treatment) | |
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| Inpatient | $250 copay/treatment course; 100% of contracted charges | Not Covered | |
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| Detoxification | $0 copay; 100% of covered charges up to a maximum payment of $2,000/calendar year. | Not Covered | |
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| Outpatient or Residential Treatment Center | $0 copay; 100% of contracted charges | Not Covered | |
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| Maximums | Annual - 1 treatment course; Lifetime - 2 treatment courses or $37,500, whichever is reached first. | Not Covered | |
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