| 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 Maximum Benefit |
$1,000,000
Per Individual
|
$1,000,000
Per Individual
|
|
|
|
Physician Care |
| Office Visit |
$20
Co-pay
$100 Maximum per Visit
80% After Deductible
|
$20
Co-pay
$100 Maximum per Visit
60% After Deductible
|
| (General
Practice, Family Practice, Internal Medicine, OB-GYN & Pediatric
Physicians Included) |
| |
|
Specialist Care |
| Office Visit |
$35
Co-pay
$100 Maximum per Visit
80% After Deductible
|
$35
Co-pay
$100 Maximum per Visit
60% After Deductible
|
| Diagnostic Testing |
80%
After Deductible
|
60%
After Deductible
|
| Phys,Occ,Speech Therapy |
80%
After Deductible
|
60%
After Deductible
|
| Covered
office visit charges include: Physician Consult Fee, Diagnostic
Lab Testing, X-Rays and Injections performed in-office |
| |
|
|
| 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). 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. |
| Ambulatory
Surgery, Cat Scan & MRI |
80%
After Deductible
|
60%
After Deductible
|
| |
| Home Care |
Not
Covered
|
Not
Covered
|
| |
|
|
| Maternity |
Same
as any other illness
$5,000 Maximum per Year
|
|
| |
|
| Mental Health |
Not
Covered
|
| |
| Substance Abuse |
Not
Covered
|
| |
| Wellness Benefit |
100%
after $20 Co-Pay, Up To $200 Per Calendar Year
|
|
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 |
$15
Maximum per Visit
$150 Maximum per Year
|
$15
Maximum per Visit
$150 Maximum per Year
|
| |
| Prescription Drug |
Generic:
$10 Co-pay
Brand: Avg. Wholesale Price less 12% (or lower promotional cost
if available)
|
N/A
|
| Mail Order |
Generic:
$20 Co-pay
Brand: Average Wholesale
Price Less 16%
|
|
| Annual Limit |
$1,500 Per Individual
|
|
| |
|
|
| Immune System, Cardiovascular and Cancer-Related disorders |
$5,000
Maximum Out-Patient Benefit Limit per Calendar Year
|
|
| |
| Organ Transplant |
Annual Plan Limits Apply
$100,000 Lifetime Benefit
|
N/A
|
| |
| Vision Benefits |
Annual spectacle eye exam for $15 co-pay. Frames and lens or Contacts covered
for $15 co-pay. Honored at over 6,500 locations nationally, including
JCPenny Optical, Sears Optical, Pearle Vision, Target Optical, and
thousands of Independent Providers. |
|
Non-Network
Coverage for Out-Patient treatment benefits limited to $25,000
per calendar year per individual.
|
| Medically Underwritten |
The NATIONAL 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 SCHEDULE OF BENEFITS SUMMARY DESCRIBED HEREIN IS
FOR ILLUSTRATIVE PURPOSES ONLY. REFER TO THE PLAN DOCUMENT AND SUMMARY
PLAN DESCRIPTION FOR SPECIFIC BENEFITS AND EXCLUSIONS. Rev. 01-02 |
|
|
|
|
