|
2010 High Option Benefits
|
|
Covered Services
|
What you pay with
PPO Benefits
|
What you pay with
Non-PPO Benefits
|
|
PREVENTIVE CARE
|
|
|
Well-child Office Visits
|
Nothing for covered charges |
30%* of the Plan allowance |
| Adult/Child Immunizations |
Nothing for covered charges |
Nothing for covered charges |
| Cancer Screening |
Nothing for covered charges |
30%* of the Plan allowance |
| Annual Physicals |
$20 copay per office visit |
30%* of the Plan allowance |
|
PHYSICIAN CARE
|
|
| Doctor’s Office Visits |
$20 copay per office visit |
30%* of the Plan allowance |
| Maternity Care |
10%* of covered charges |
30%* of the Plan allowance |
|
HOSPITAL CARE
|
|
|
Inpatient
|
Nothing for room and board, 10% after $200 copay per admission
|
30%* after $300 copay per admission
|
|
Outpatient
|
10% of covered charges, $100 copay
|
30%* of the Plan allowance, $150 copay
|
|
Surgery
|
10%* of covered charges
|
30%* of the Plan allowance
|
|
EMERGENCY CARE
|
|
Accidental Injury
|
Nothing within 72 hours
|
Nothing within 72 hours
|
|
Medical Emergency
|
Regular benefits apply
|
Regular benefits apply
|
|
PRESCRIPTION DRUGS
|
|
Retail1
(up to a 30-day supply)
|
$10 generic
15% ($35 minimum/$50 maximum) preferred name brand
30% ($50 minimum/$80 maximum) non-preferred name brand
|
|
Mail Order1
(up to a 90-day supply)
|
$10 generic
15% ($50 minimum/$80 maximum) preferred name brand
30% ($65 minimum/$95 maximum)
non-preferred name brand
|
Medicare Part B: $10 generic
Medicare Part B: 15% ($30 minimum/ $65 maximum) preferred name brand
Medicare Part B: 30% ($50 minimum/ $80 maximum) preferred name brand
|
|
OTHER BENEFITS
|
|
Lab and X-rays
|
10% of covered charges
Nothing for Quest Lab services
|
30%* of the Plan allowance
|
|
Hearing Services
|
10%* of covered charges
|
30%* of the Plan allowance
|
|
Catastrophic Benefits
|
Nothing after $3,500 for you and your family members
|
Nothing after $5,000 for you and your family members
|
