| |
HMO |
PPO |
| |
Plan 1 |
In Network |
Out of Network |
| Lifetime Maximum |
Unlimited |
$5 million |
$5 million |
| Deductible |
| Single |
n/a |
$250 |
$250 |
| Family |
n/a |
$500 |
$500 |
| Out of Pocket Maximum* |
| Single |
$1,500 |
$1,000 |
$1,000 |
| Family |
$3,000 |
$2,000 |
$2,000 |
| Prescription Drug Benefit (Pharmacy - 30 Day Supply) |
| Generic |
$7 |
$7 |
60% after CYD |
| Preferred Brand Name |
$20 (all Brand Names) |
$20 (all Brand Names) |
60% after CYD |
| Non-Preferred brand Name |
n/a |
n/a |
n/a |
| Prescription Drug Benefit (Mail Order - 90 Day Supply) |
| Generic |
$14 |
$14 |
60% after CYD |
| Preferred Brand Name |
$40 (all Brand Names) |
$40 (all Brand Names) |
60% after CYD |
| Non-Preferred Brand Name |
n/a |
n/a |
60% after CYD |
| Hospital Services |
| Inpatient Surgery |
$0 per admission |
90% after CYD |
60% after CYD & $300 PAD |
| Outpatient Surgeryt |
$0 copay |
90% after CYD |
60% after CYD |
| Obstetrical Care & Delivery |
$0 per admission |
90% after CYD |
60% after CYD & $300 PAD |
| Emergency Room |
$25 per visit |
90% after CYD |
60% after CYD |
| Mental & Nervous Benefit |
| Outpatient |
$25 per visit (limited to 20 visits/CY) |
90% after CYD (limited to 20 visits/CY) |
60% after CYD (limited to 20 visits/CY) |
| Inpatient |
$0 copay (limited to 30 days/CY) |
90% after CYD (limited to 30 days/CY) |
60% after CYD & PAD (limited to 30 days/CY) |
| Alcohol & Drug Abuse Benefit- Limited to $2500 |
| Outpatient |
$15 per visit (limited to 20 visits/CY) |
90% after CYD (limited to 44 visits per lifetime) |
60% after CYD (limited to 44 visits per lifetime) |
| Inpatient |
$0 copay (detoxification only) |
90% after CYD (limited to 30 days/CY) |
60% after CYD & PAD (limited to 30 days/CY) |
* - Does not include Prescription Drug Copays
CY = Calendar Year
CYD = Calendar Year Deductible
PAD = Per Admission Deductible
|
