| General | This self-pay option does not provide coverage for any dependents. Effective 1/1/2011, Lower Cost Self-Pay participants who previously had Plan I Earned Eligibility will receive mental health/chemical dependency benefits at the same levels as the hospital/major medical benefits outlined below. The mental health/chemical dependency benefits are administered by ValueOptions. Mental health/chemical dependency benefits are not covered for Lower Cost Self-Pay participants who previously had Plan II Earned
Eligibility.
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| HOSPITAL
| NETWORK PROVIDER | Effective 1/1/2010, hospital coverage limited to Network hospitals only NATIONWIDE
NON-NETWORK PROVIDER | |
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NATIONWIDE |
CALIFORNIA |
NON-CALIFORNIA |
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| Calendar Year Deductible | $500/person
Industry Health Network
$150/person | No coverage | No coverage
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| Inpatient (Room/Board/Ancillary Svcs.) | 90% | No coverage | No coverage |
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| Outpatient Surgery | 90% | No coverage | No coverage |
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| Emergency Room | 90% after $200 co-pay; co-pay is waived if patient admitted
| No coverage* | No coverage* |
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| Out-of-Pocket Maximum | $1,250/person | No coverage | No coverage |
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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 | |
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| Calendar Year Deductible | $500/person
Industry Health Network -
No Deductible for IHN | $750/person
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| Office Visit/X-Ray/Lab | 90% after $25 copay
| 70% |
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| Surgeon - Inpatient | 90% after $100 copay
| 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
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70% |
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| 90% after $25 co-pay for surgery in a doctor's office
| 70% |
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| Maternity Care | 90% after $100 co-pay | 70% |
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| Routine Physical Exam
| No deductible;
100%
| No coverage |
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| Well Child | No deductible;
100%
| No coverage |
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| Well Woman (Mammogram/Pap) | No deductible;
100%
| 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 (after Deductible) | $1,000/person | $2,500/person |
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| Hospital/Major Medical Lifetime Maximum | None | |
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PRESCRIPTION DRUGS | | | |
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| 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.
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: $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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