Benefit

In-Network

Out-of-Network

Deductible/Individual

                    Family

$500

$1500

$1000

$3000

Coinsurance

80% after deductible until out-of pocket max. is met; then 100%

$5000 Individual

$10,000 Family

Out-of-Pocket Max.

$2500 Individual

$5000 Family

$5000 Individual

$10,000 Family

Lifetime Maximum

$2,000,000

(includes out-of-network payments)

$300,000

(applied to total lifetime max.)

Physician Office Visits

100% after $20 copayment

60% after deductible

Limit: 15 visits/year

Preventative Care

Adult Routine Physicals

Routine Gyne, incl. PAP

Mammograms, as required

100% after $20 copayment

100% after $20 copayment

100%

Not covered

60% (deductible does not apply)

60% after deductible

Pediatric Routine Physical

Pediatric Immunizations

100% after $20 copayment

100%

Not covered

60% (deduc. does not apply)

Emergency Room Services

100% after $50 copayment

(waived if admitted)

Ambulance

80% after deductible

Hospital Expenses/Inpatient

                                 Outpatient

80% after deductible

80% after deductible

60% after deductible. (Limit: 90 days/year)

60% after deductible

Maternity

80% after deductible

60% after deductible (day limit is part of inpatient hospital day limit)

Infertility Counseling, testing & Treatment

80% after deductible

60% after deductible

Assisted Fertilization Procedures

Excludes all assisted fertilization procedures

Medical/Surgical Expenses

80% after deductible

60% after deductible

Spinal Manipulations

80% after deductible

60% after deductible

Diagnostic Services (Lab, X-ray, and other tests)

80% after deductible

60% after deductible

Physical Therapy (Professional)

80% after deductible

60% after deductible

Speech & Occupational Therapy (Professional)

80% after deductible

Durable Medical Equipment

80% after deductible

Skilled Nursing Facility Care

80% after deductible (Limit: 100 days/year)

Home Health Care

80% after deductible (Limit: 100 visits/year)

Private Duty Nursing

80% after deductible (Limit: $20,000/year)

Hospice

80% after deductible

Mental Health/Inpatient

                        Outpatient

80% after deductible (Limit: 30 days/yr)

80% after deductible & $20 copayment

60% after deductible (Limit: 10 days /yr)

50% after deductible

Substance Abuse

Inpatient Detoxification

Inpatient Rehabilitation

Outpatient

80% after deductible

(Limit:7 days/admission; 4 admissions lifetime)

80% after deductible

(Limit:30 days/year; 90 days lifetime)

80% after deductible & $20 copay

(Limit: 60 visits/year; 120 visits lifetime)

60% after deductible

(Limit:7 days/admission; 4 admissions lifetime)

60% after deductible

(Limit:30 days/year; 90 days lifetime)

50% after deductible & $20 copay

(Limit: 60 visits/year; 120 visits lifetime)

Precertification Requirements

Performed by Provider

Performed by Member

Premier Prescription Drug Program

31-day supply

$10 copay generic; $30 copay brand

Closed Formulary; Mandatory Generic

Mail Order

90 day supply

$20 copy generic; $60 copy brand

Closed Formulary; Mandatory Generic