|
Benefit Description |
Prime
(Prime
High #N077) |
HRA/PPO (#N954)
|
|
|
|
80% for In Network 60%
for Out of Network |
|
Lifetime Maximum
Benefit |
$2,000,000 |
$2,000,000 |
|
Annual Max Out of
Pocket |
$1,000 / person |
$3,000/$6,000 Ind/Fam |
|
Annual Deductible |
None |
$1500/$3000 Ind/fam |
|
Preventive Care |
|
Deductible waived on
Preventive Care |
|
·
Well Baby Care |
100% after $15 copay |
80% Paid |
|
·
Routine Physicals |
100% after $15 copay |
80% Paid |
|
·
Routine Gynecological Exams |
100% after $15 copay |
100% after $15 copay
|
|
·
Immunizations |
100% paid |
100% after $10 copay
|
|
Professional Services |
|
|
|
·
Office and Home Visits |
100% after $15 copay |
80% After Deductible |
|
·
Urgent Care Center Visits |
100% after $15 copay |
80% After Deductible |
|
·
Surgery |
100% paid |
80% After Deductible |
|
|
|
|
|
Hospital Services |
|
|
|
·
Inpatient Room & Board |
100% after $100 copay/day |
80% After Deductible |
|
·
Inpatient Rehabilitative Care |
100% after $100 copay/day |
80% After Deductible |
|
·
Skilled Nursing Facility Care |
100% after $100 copay/day |
80% After Deductible |
|
Outpatient Services |
|
|
|
·
Outpatient Surgery |
100% paid |
80% After Deductible |
|
·
Diagnostic Lab & X-ray |
100% paid |
80% After Deductible |
|
·
CT Scans / MRIs |
100% paid |
80% After Deductible |
|
·
Emergency Room Visits |
100% after $50 copay |
80% After Deductible |
|
Mental Health/Chem Dep
Services |
|
|
|
·
Office Visits |
100% after $15 copay |
80% After Deductible |
|
·
Inpatient Care |
80% paid |
80% After
Deductible |
|
·
Residential Programs |
80% paid |
80% After
Deductible |
|
Other Covered Services |
|
|
|
·
Physical Therapy (30 sessions max/year) |
100% after $15 copay |
80% After
Deductible |
|
·
Therapeutic Injections (allergy shots) |
100% |
80% After
Deductible |
|
·
Ground Ambulance (300 miles max/year) |
80% paid |
80% After
Deductible ($5,000 annual max) |
|
·
Air Ambulance (to nearest facility) |
80% paid |
80% After Deductible
($5,000 annual max) |
|
·
Durable Medical Equipment |
80% paid |
80% After Deductible |
|
·
Home Health Care |
100% paid |
80% After Deductible |
|
Audiology Exam/Original
Hardware ($500 max
benefit/36 months for hardware) |
50% UCR |
50% UCR |
|
Alternative Care
($1000 annual limit) |
|
|
|
Chiropractic |
No Benefit |
$15 copay (not subject to
deductible) |
|
Acupuncture |
No Benefit |
$15 copay (not
subject to deductible) |
|
Naturopathic |
No Benefit |
$15 copay (not
subject to deductible) |
|
|
|
|
|
Prescription Drugs |
|
|
|
·
Formulary Generic |
$10 copay |
80% After Deductible |
|
·
Formulary Brand Name |
$20 copay |
80% After Deductible |
|
·
Non-Formulary |
$30 copay |
80% After Deductible |
|
Dosage Limit |
|
|
|
·
Local Pharmacy |
1 copay/34 day supply |
34 day supply |
|
·
Mail Order Pharmacy |
2 copay/90 day supply |
90 day supply |
|
Vision |
|
|
|
Frequency of Services |
|
|
|
·
Exam, Lenses & Frames |
Once every 24 months |
Once every 24 months |
|
Benefits |
|
|
|
·
Exam |
100% paid |
100% paid |
|
·
Single Vision Lenses |
100% up to $56 |
100% up to $56 |
|
·
Bifocal Lenses |
100% up to $84 |
100% up to $84 |
|
·
Trifocal Lenses |
100% up to $116 |
100% up to $116 |
|
·
Lenticular Lenses |
100% up to $236 |
100% up to $236 |
|
·
Frames |
100% up to $75 |
100% up to $75 |
|
·
Contacts |
100% up to $131 |
100% up to $131 |
