| General | This self-pay option does not provide coverage for any dependents. Effective 1/1/09, Lower Cost Self-Pay participants are covered under the mental health/chemical dependency plan they were covered under when they had Earned Eligibility.
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| HOSPITAL
| NETWORK PROVIDER | 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 | $750/person
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| Inpatient (Room/Board/Ancillary Svcs.) | 100% | No coverage | 80% |
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| Outpatient Surgery | 100% | No coverage | 80% |
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| Emergency Room | 100% after $200 copay; copay is waived if patient admitted
| No coverage | 80% |
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| Out-of-Pocket Maximum | N/A | No coverage | No maximum |
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MAJOR MEDICAL | |
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| Calendar Year Deductible | $500/person
Industry Health Network
$150 per person
Effective 1/1/09: No Deductible for IHN | $750/person
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| Office Visit/X-Ray/Lab | 100% after $25 copay
| 70% |
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| Surgeon - Inpatient | 100% after $100 copay
| 70%
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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
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70% |
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| 100% after $25 copay for surgery in a doctor's office
| 70% |
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| Maternity Care | 100% after $100 copay | 70% |
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| Routine Physical Exam (age 40 or over)
| 100% after $25 copay
| Not Covered |
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| Well Child (to age 6) | 100% after $25 copay
| Not Covered |
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| Well Woman (Mammogram/Pap) | 100% after $25 copay
| 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) | N/A | $1,500/person |
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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 limit on your out-of-pocket expenses for mail order drugs is $75 per prescription (after the calendar year deductible). Effective 1/1/09, the maximum co-payment for specialty drugs will be $100 per prescription (after the calendar year deductible).
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