| Benefit |
Network
|
Non-Network
|
| Financial |
| Deductible |
$500
Individual
$1,500 Family
|
$1,000
Individual
$3,000 Family
|
| Payment Percentage |
80%
|
60%
|
Payment Percentage Limit
($10,000) |
$2,000
Individual
$6,000 Family
|
$4,000
Individual
$12,000 Family
|
| Lifetime Maximum Benefit |
$2,000,000
Per Individual
|
$2,000,000
Per Individual
|
| |
| Physician Care |
| Office Visit |
$20
Co-pay
|
60%
After Deductible
|
| After Hours/Home |
80%
After Deductible
|
60%
After Deductible
|
| |
| Specialist Care |
| Office Visit |
$30
Co-pay
|
60%
After Deductible
|
| Diagnostic Testing |
80%
After Deductible
|
60%
After Deductible
|
| Phys,Occ,Speech Therapy |
80%
After Deductible
|
60%
After Deductible
|
| |
|
|
| Outpatient Services |
80%
After Deductible
|
60%
After Deductible
|
| |
|
|
| Hospital Services |
80%
After Deductible
|
60%
After Deductible
|
| |
|
|
| Skilled Nursing Facility |
80%
After Deductible
|
60%
After Deductible
|
| |
|
|
| Emergency Room |
80%
After Deductible
|
60%
After Deductible
|
| |
|
|
| Home Care |
80%
After Deductible
|
60%
After Deductible
|
| |
|
|
| Maternity |
Same
as any other illness
|
Same
as any other illness
|
| |
|
| Mental Health |
$5,000
Maximum Per Year / $25,000 Maximum Lifetime
|
| Inpatient |
80% After Deductible
Maximum 14 Days per Year
|
50% After Deductible
Maximum 14 Days per Year
|
| Outpatient |
80% After Deductible
$50 Maximum per Visit
Maximum 15 Visits per Year
|
50% After Deductible
$50 Maximum per Visit
Maximum 15 Visits per Year
|
| |
|
|
| Substance Abuse |
$5,000
Maximum Per Year / $25,000 Maximum Lifetime
|
| Inpatient Rehab |
80% After Deductible
Maximum 14 Days per Year
|
50% After Deductible
Maximum 14 Days per Year
|
| Outpatient Rehab |
80% After Deductible
$50 Maximum per Year
Maximum 15 Visits per Year
|
50% After Deductible
$50 Maximum per Visit
Maximum 15 Visits per Year
|
| |
|
|
| 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 Inoculations, Pap Smears and OB-GYN
Exams, PSA/prostate exams, Mammograms, Flu Shots, & Well Baby
Care. |
| |
|
|
| Chiropractic |
$20
Co-Pay
$100 Maximum per Visit
$500 Maximum per Year
|
$35
Co-Pay
$100 Maximum per Visit
$500 Maximum per Year
|
| |
|
|
| Prescription Drug |
$15
Generic, $30 Preferred Brand, $50 Non-Preferred Brand
|
NA
|
| Mail Order |
2
x Retail Co-Pay
|
|
| Annual Limit |
$2,000
Per Individual
|
|
| |
|
|
| Durable Medical Equipment |
90%
After Deductible
$5,000 Annual Maximum
|
70%
After Deductible
$5,000 Annual Maximum
|
| |
| 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. |
| |
| 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 |
|
|
|
|
