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Overview of Coverage

Payment Level In-Network Deductible Office Visits Emergency Room Services
90% 70% $250 - Individual
$250/$375 - Parent/Child(ren),
$250/$500 Husband/Wife Employee/Partner, Family
 $10/$20 Copay $100 Copay
Benefit/Service In-Network Out-of-Network
Benefit Period Twelve months beginning on the contract date
Deductible per benefit period $250: Individual
$250/$375: Parent/Child
$250/$500: Husband/Wife, Employee/Partner, Family
 $500 Individual
$1,000 Family Aggregate
Payment Level based on Provider's Reasonable Charge (PRC)
 90% PRC after deductible until out-of-pocket limit is met; then 100% PRC
 70% PRC after deductible until out-of-pocket limit is met; then 100% PRC
Out-of-Pocket Limit
Includes Coinsurance, certain exclusions may apply
 $1,000: Individual
$1,000/$1,500:Parent/Child(ren)
$1,000/$2,000: Husband/Wife, Employee/Partner, Family
 $2,000 Individual
$4,000 Family Aggregate
Autism Spectrum Disorders Max per person $36,000/benefit period
Lifetime Maximum Unlimited Unlimited
Ambulance 90% PRC after deductible
 70% PRC after deductible
Applied Behavior Analysis for Autism Spectrum 90% PRC after deductible 70% PRC after deductible
Assisted Fertilization Procedures 90% PRC after deductible 70% PRC after deductible
$2,500 maximum per lifetime
Dental Services Related to an Accidental Injury 90% PRC after deductible 70% PRC after deductible
Limited to surgery within 24 hours of accident
Diabetes Treatment 90% PRC after deductible 70% PRC after deductible
Diagnostic Services
Lab, X-ray, and medical tests		 90% PRC after deductible 70% PRC after deductible
Durable Medical Equipment, Orthotics and Prosthetics 90% PRC after deductible 70% PRC after deductible
Emergency Room Services 100% PRC after $100 Copay – waived if admitted
Hearing Care Services 90% PRC after deductible
$700 limit per 36 months for the purchase of a hearing aid device and audiometric testing
Home Health Care
Excludes Respite Care		 90% PRC after deductible 70% PRC after deductible
120 visits/benefit period
Hospice
Includes Respite Care		 90% PRC after deductible 70% PRC after deductible
Hospital Expenses
Inpatient and Outpatient		 90% PRC after deductible 70% PRC after deductible
Infertility Counseling, Testing and Treatment 90% PRC after deductible 70% PRC after deductible
Maternity Includes Dependent Daughters 90% PRC after deductible 70% PRC after deductible
Medical Care Inpatient 90% PRC after deductible 70% PRC after deductible
Mental Health Inpatient 90% PRC after deductible 70% PRC after deductible
Mental Health Outpatient 100% PRC after $10 Copay 70% PRC after deductible
Occupational Therapy Outpatient 100% PRC after $20 Copay 70% PRC after deductible
24 visits/benefit period
Office Visits Primary Care Physician: 100% PRC after $10 Copay
70% PRC after deductible
Specialist: 100% PRC
after $20 Copay
Oral Surgery 90% PRC after deductible 70% PRC after deductible
Physical Medicine Outpatient 100% PRC after $20 Copay 70% PRC after deductible
24 visits/benefit period
Adult Preventive Care Which Includes:
Routine Physical Exam 100% PRC 70% PRC after deductible
Immunizations 100% PRC
 70% PRC after deductible
Routine Diagnostic Screening 100% PRC
 70% PRC after deductible
Screening Mammography 100% PRC
 70% PRC after deductible
Routine Gynecological Exam & Pap Test 100% PRC
 70% PRC no deductible/ lifetime maximum
Pediatric Preventative Care Which Includes:
Routine Physical Exams 100% PRC 70% PRC after deductible
Pediatric Immunizations 100% PRC
 70% PRC no deductible/ lifetime maximum
Routine Diagnostic Screening 100% PRC
 70% PRC after deductible
Private Duty Nursing 90% PRC after deductible 70% PRC after deductible
240 hours/benefit period
Skilled Nursing Facility Care 90% PRC after deductible 70% PRC after deductible
100 days/benefit period
Speech Therapy Outpatient 100% PRC after $20 Copay 70% PRC after deductible
24 visits/benefit period
Spinal Manipulations Outpatient 100% PRC after $20 Copay 70% PRC after deductible
24 visits/benefit period
Substance Abuse:
Detoxification 90% PRC after deductible 70% PRC after deductible
Inpatient Rehabilitation 90% PRC after deductible 70% PRC after deductible
Outpatient 100% PRC after $20 Copay 70% PRC after deductible
Surgical Expenses 90% PRC after deductible 70% PRC after deductible
Gastric Bypass/Bariatric Surgery 90% PRC after deductible Not Covered
Therapy and Rehabilitation Services
Chemotherapy, Radiation Therapy, Dialysis, Infusion Therapy, Respiratory Therapy		 90% PRC after deductible 70% PRC after deductible
Transplant Services 90% PRC after deductible Not Covered
Wigs
Cancer Diagnosis Only		 90% PRC after deductible
$300 maximum per lifetime
Precertification Requirements for Inpatient Admissions Performed by Network Provider Performed by Member
Condition Management Case Management, Blues on Call, and Disease State Management
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