National Media Benefits - Basic Care I Plan
Covered
Benefits: $50,000 CALENDAR YEAR Maximum Per Individual
$1,000,000 Lifetime Maximum Benefit Per Individual
| Benefit | Network | Non-Network | |
| Financial | |||
| Deductible | $250 Individual / $750 Family | $500 Individual / $1,500 Family | |
| Coinsurance | 80% | 60% | |
| Coinsurance Limit | $2,000 Individual / $6,000 Family | $4,000 Individual / $12,000 Family | |
| Lifetime Max Benefit | $50,000 Per Individual | $50,000 Per Individual | |
| Physician Care | |||
| Office Visit | $20 Co-pay; $100 Max/Visit then 80% After Deductible | $20 Co-pay; $100 Max/Visit then 60% After Deductible | |
| (General Practice, Family Practice, Internal Medicine, OB-GYN & Pediatric Physicians Included) | |||
| Specialty Care | |||
| Office Visits | $35 Co-pay; $100 Max/Visit then 80% After Deductible | $35 Co-pay; $100 Max/Visit then 60% After Deductible | |
| Diagnostic Testing | 80% After Deductible | 60% After Deductible | |
| Phys,Occ,Speech Therapy | 80% After Deductible | 60% After Deductible | |
| Covered
office visits include: Physician Consult Fee, In-Office Diagnostic Lab Testing,
X-Rays and Injections *Balance subject to the in-network benefit level (deductible, out-of-pocket, and coinsurance) |
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| Hospital Services | |||
| Inpatient | 80% After Deductible | 60% After Deductible | |
| X-Ray & Laboratory | 80% After Deductible | 60% After Deductible | |
| Out-Patient | 80% After Deductible | 60% After Deductible | |
| Emergency Room** | 80% After Deductible | 60% After Deductible | |
| **Hospital
Emergency Room is subject to $50 Co-payment (in addition to applicable deductible
and coinsurance) $50 Co-Payment waived if admitted within 72 hours to hospital. (Emergency confinements must be certified within 2 working days of admission) Any Hospital Confinement that is not pre-certified as required will result in a 50% reduction of benefits for that confinement. |
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| Ambulatory Surgery, Cat Scan & MRI*** | 80% After Deductible | 60% After Deductible | |
| *** Any of these services performed at any facility other than a Network Hospital are subject to the out-of-network benefit level. | |||
| Home Care | Not Covered | Not Covered | |
| Maternity | Treated as any other medical condition; $5,000 Max/Year | ||
| Mental Health |
Not
Covered
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| Substance Abuse |
Not
Covered
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| Wellness Benefit |
100%
after $20 Co-Pay, Up To $200 Per Calendar Year
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| Covered services include: Routine Physicals with X-ray and Lab Tests, Vaccinations and Innoculations, Pap Smears and OB-GYN Exams, PSA/prostate exams, Mammograms, Flu Shots, & Well Baby Care. | |||
| Chiropractic | 100% after $20 Co-pay;$100 Max/Visit, $500 Max/Year | ||
| Prescription Drug Retail (30-day supply per prescription) Mail Order (90-day supply per prescription) (Calendar year deductible and coinsurance DO NOT APPLY to the In-Network Prescription Drug expenses.) |
Generic:
100% after $10 Co-pay
Brand: Average Wholesale Price Less 12% (or lower promotional cost if available) Generic: 100% after $20 Co-pay Brand: Average Wholesale Price Less 16% |
N/A | |
| Immune System, Cardiovascular and Cancer-Related disorders | $5,000 Maximum Out-Patient Benefit Limit per Calendar Year | ||
| Organ Transplant | Limited to $100,000 Lifetime Benefit | N/A | |
| Dental
Discount Benefits: Honored at over 11,000 providers nationwide. Low, pre-negotiated
fees on most dental procedures. Savings of 10% to 50% of usual and customary charges in the area. |
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| Vision BenefitsHonored at over 6,500 locations nationally, including J.C. Penny Optical, Sears Optical, Pearle Vision, Target Optical, and more. Annual wellness eye exam for $20 co-pay. Discounts up to 60% on frames, 45% on bifocals & up to 20% on contact lenses. | |||
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Out-of-Network
Coverage for Out-Patient treatment benefits limited to $25,000 per calendar
year per individual.
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| Medically Underwritten | The American Media Benefits PPO rates are subject to underwriting approval. | ||
| Dependent Children covered to the end of the 18th year. Coverage
will extend through 23rd year with proof of enrollment at an
accredited learning institution.Pre-Certification required or benefits paid
will be reduced. Emergency Room notification is required within 48 hours.
Pre-Certification determines medical necessity only. It is not a commitment
for payment of any incurred claims expense. THE SUMMARY OF PLAN BENEFITS DESCRIBED HEREIN IS FOR ILLUSTRATIVE PURPOSES ONLY.REFER TO THE PLAN DOCUMENT FOR SPECIFIC BENEFITS AND EXCLUSIONS.Rev. 11-23-01 |
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